`
EFFECTIVENESS OF SANITATION AND HYGIENE
INTERVENTIONS IN CHANGING MOTHERS’
BEHAVIOUR AND IMPROVING CHILD HEALTH IN
TURKANA DISTRICT KENYA
JOHN GACHUKI KARIUKI
DOCTOR OF PHILOSOPHY
(Public Health)
JOMO KENYATTA UNIVERSITY OF
AGRICULTURE AND TECHNOLOGY
2013
`
Effectiveness of sanitation and hygiene interventions in
changing mothers’ behaviour and improving child health in
Turkana District, Kenya.
John Gachuki Kariuki
A thesis submitted in partial fulfilment for the degree of Doctor of
Philosophy in Public Health in the Jomo Kenyatta
University of Agriculture and Technology
2013
DECLARATION
This thesis is my original work and has not been presented for a degree in any other
university or institution.
Signature………………………
John Gachuki Kariuki
Date…………………….
DECLARATION BY SUPERVISORS
This thesis has been submitted for examination with our approval as University
Supervisors.
Signature………………………
Prof. Japhet K. Magambo (Ph.D)
JKUAT, Kenya.
Date…………………….
Signature………………………
Prof. Francis M. Njeruh (Ph.D)
JKUAT, Kenya.
Date…………………….
Signature………………………
Dr. Samuel Kariuki (Ph.D)
KEMRI, Kenya.
Date…………………….
Signature………………………
Date…………………….
Dr. Eric M. Muchiri (Ph.D)
Ministry of Public Health and Sanitation, Kenya.
ii
DEDICATION
The work is dedicated to my wife Margaret, children (Kenneth, Lysbeth, Ann and Peter)
and to all Public Health Practitioners worldwide.
iii
ACKNOWLEDGEMENT
I wish to extend my acknowledgments to various persons and institutions for the
contributions they made towards completion of this work. First, I thank the Ministry of
Public Health and Sanitation through the Chief Public Health Officer for accepting to
pay my tuition fees and the Directorate of Personnel Management (DPM) for granting
me course approval and study leave.
Secondly, I thank my four supervisors, Prof. Japhet K. Magambo, Prof. Francis M.
Njeruh, Dr. Samuel Kariuki and Dr. Eric M. Muchiri, for finding time and according me
good supervision, during our many meetings and discussions throughout the study
period, and for coming to the field to oversee my field research.
Thirdly, I thank the United Nations Children’s Fund (UNICEF) Kenya Country office
through Eng. Fredrick Donde for their financial and logistical support for the field
work. I also thank Mr. Bore and acknowledge the support from the National Bureau of
Statistics for identification, mapping and listing of population study clusters.
Equally, I cannot forget to acknowledge Dr. Joseph Karemi; the Medical Officer of
Health Turkana District, and Dr. Eric J. Ahomo; the Medical Superintendent Lodwar
District hospital who allowed to me to use their facilities, and their staff; namely
Innocent Munyefu Sifuna, Chrysantus Ahindukha Lirhunde, Alfred Ikenyi Emanman,
iv
Scholastica L . Ekorot, Julia A. Akorilem and Daniel Esimit, who assisted in the field
work. In addition, I also wish to thank Dr. Samuel Kariuki of Kenya Medical Research
Institute (KEMRI) and their staff Ayub Ongechi and Peter Mbogo for assisting in
laboratory analysis of study specimen.
Finally I am greatly indebted to the heads of the house-holds who allowed me access to
their compounds to conduct general hygiene and sanitation inspection, interview
mothers of children less than five years of age, from whom I collected stool specimens
from their children and water samples from their storage containers for microbiological
test.
v
TABLE OF CONTENTS
DECLARATION ......................................................................................................................... ii
DEDICATION ............................................................................................................................ iii
ACKNOWLEDGEMENT ......................................................................................................... iv
TABLE OF CONTENTS ........................................................................................................... vi
LIST OF TABLES ..................................................................................................................... ix
LIST OF FIGURES .................................................................................................................... x
LIST OF APPENDICES ............................................................................................................ xi
LIST OF ABBREVIATIONS AND ACRONYMS................................................................. xii
OPERATIONAL DEFINITIONS ........................................................................................... xiv
ABSTRACT ............................................................................................................................... xv
CHAPTER ONE .......................................................................................................................... 1
1.0
INTRODUCTION ........................................................................................................... 1
1.1
Background ................................................................................................................... 1
1.2
Problem Statement ........................................................................................................ 2
1.3
Study Justification ......................................................................................................... 5
1.4
Study Questions............................................................................................................. 7
1.5
Objectives ...................................................................................................................... 8
1.6
Hypotheses .................................................................................................................... 9
1.7
Theoretical Framework: precede-proceed model ........................................................ 10
CHAPTER TWO....................................................................................................................... 14
2.0
LITERATURE REVIEW ............................................................................................. 14
2.1
Global concern on water and sanitation impacts on health ......................................... 14
2.2
Disease burden due to environmental hygiene and sanitation ..................................... 17
vi
2.3
Notable environmental hygiene and sanitation interventions...................................... 20
2.4
Effectiveness of WASH interventions in Reducing Diarrhoea Morbidity .................. 29
2.5
Role of advocacy as a software approach in hygiene and sanitation promotion ......... 33
CHAPTER THREE .................................................................................................................. 35
3.0
METHODS AND MATERIALS .................................................................................. 35
3.1
Study Area ................................................................................................................... 35
3.2
Study population ......................................................................................................... 35
3.3
Inclusion/Exclusion criteria ......................................................................................... 35
3.4
Ethical Issues ............................................................................................................... 35
3.5
Study design ................................................................................................................ 36
3.6
Sample size determination........................................................................................... 37
3.7
Population Sampling Procedure .................................................................................. 38
3.8
Data collection methods .............................................................................................. 39
3.9
Data Management and analysis ................................................................................... 45
3.10
Study Limitations ........................................................................................................ 46
CHAPTER FOUR ..................................................................................................................... 47
4.0
RESULTS ....................................................................................................................... 47
4.1
General overview ........................................................................................................ 47
4.2
Key Demographic Variables ....................................................................................... 47
4.3
Knowledge and Practices of Sanitation and Hygiene Before and After Intervention . 54
4.4
Change in Health Outcome as Measured by Surrogate Parameters ............................ 61
4.5
Linkages between mother’s behaviour and targeted health improvement indicators.. 68
CHAPTER FIVE ....................................................................................................................... 77
5.0
DISCUSSION, CONCLUSION AND RECOMMENDATIONS .............................. 77
vii
5.1
Discussion ................................................................................................................... 77
5.2
Conclusions ................................................................................................................. 87
5.3
Recommendations ....................................................................................................... 89
REFERENCES .......................................................................................................................... 91
APPENDICES ......................................................................................................................... 102
viii
LIST OF TABLES
Table 1:
Reason for not having toilet facility (2007 and 2008) .............................................. 54
Table 2:
Cross-tabulation of whether latrine is important in 2007 and in 2008 ..................... 55
Table 3:
Knowledge on diseases associated with drinking unsafe water ............................... 56
Table 4:
Change in hand washing prevalence (2007 and 2008) ............................................. 57
Table 5:
Change in hand washing in 2007 and 2008, grouped by age group ......................... 58
Table 6:
Presence of soap in the house in 2007 and 2008, grouped by education level ........ 58
Table 7:
Drinking water storage in 2007 and 2008, grouped by Division ............................ 59
Table 8:
Way of disposing off children faeces ...................................................................... 60
Table 9:
Chlorine Level in 2007 and in 2008 ........................................................................ 62
Table 10:
Paired Samples Statistics on faecal coliforms per 100 ml sample ......................... 63
Table 11:
Cross-tabulation on child diarrhoea at baseline and endline .................................. 65
Table 12:
Ova and Cyst and Bacterial and parasitic pathogens in stool ................................. 68
Table 13:
Association between FC change and modifiable risk factors............................... 70
Table 14:
Association of microbes in children stool and mother’s behaviour ....................... 73
Table 15:
Classification between microbes in children stool and mothers behaviour............ 74
Table 16:
Modifiable behaviour and diarrhoea in children aged less than 5 Years ............... 75
Table 17:
Association between sanitation and hygiene promotion in children ...................... 76
ix
LIST OF FIGURES
Figure 1:
Theoretical framework based on PRECEDE-PROCEDE model ........................ 13
Figure 2:
Effectiveness of WASH Interventions to reduce diarrhoea ............................... 32
Figure 3:
Distribution of Respondents by Division............................................................ 48
Figure 4:
Age distribution of study respondents ................................................................ 49
Figure 5:
Respondent’s Age Distribution by Division ....................................................... 50
Figure 6:
Highest Education Level of the Respondent....................................................... 51
Figure 7:
Distribution of Respondent’s Level of Education by Division ........................... 52
Figure 8:
Distribution of Latrine Type by Division ........................................................... 53
Figure 9:
Distribution of knowledge on latrine importance (2007 and 2008) .................... 55
Figure 10:
Contamination of compound with faecal matter ................................................. 61
Figure 11:
Diarrhoea in children in the last one month prior and after the intervention ...... 64
Figure 12:
Microbes in Stool specimens from Children Aged Less Than 5 Yrs ................ 66
Figure 13:
Diarrhoea related microbes in children at baseline and endline ......................... 67
Figure 14:
Change in faecal coliform count between 2007 and 2008 ................................... 69
Figure 15:
Normal probability plots of residuals .................................................................. 71
Figure 16:
Histogram on dispersion of residuals................................................................... 72
x
LIST OF APPENDICES
Appendix 1: HOUSEHOLD QUESTIONNAIRE................................................102
Appendix 2: WATER SAMPLING AND REPORT FORM................................118
Appendix 3: MAP OF STUDY AREA.................................................................122
Appendix 4: ETHICS AND RESEARCH CLEARANCE....................................123
Appendix 5: PUBLISHED PAPERS....................................................................126
xi
LIST OF ABBREVIATIONS AND ACRONYMS
ADB
African Development Bank
APD
Administration, Planning and development
ASAL
Arid and Semi-Arid Lands
BC
Before Christ
CBOs
Community Based Organisations
CBS
Central Bureau of Statistics
Cspro
Census for population processing
DALYS
Disability Adjusted Life Years
DFID
Department For International Development
DHS
Demographic and Health Survey
DPD
Diethyl-p-phenylenediamine
EA
Enumeration Area
GOK
Government of Kenya
IRC
International water and Sanitation research Centre
JKUAT
Jomo Kenyatta University of Agriculture and Technology
JMP
Joint Monitoring Programme
KEMRI
Kenya Medical Research Institute.
KNBS
Kenya National Bureau of Statistics
MDG
Millennium Development Goals
NGOs
None Governmental Organisations
xii
OECD
Organization for Economic Co-operation and Development
PHAST
Participatory Hygiene and Sanitation Transformation
PPS
Probability Proportion to Size
PSU
Primary Sampling Unit
SPSS
Statistical Package for
SS
Social Scientist
TNTC
Too numerous to count
TOT
Training of trainers
UK
United Kingdom
UNESCO
United Nations Educational, Scientific and Cultural Organisation
UN-HABITAT
United Nations Human Settlement programme
UNICEF
United Nation Children Fund
WASH
Water Sanitation and Hygiene
WEDC
Water Engineering Development Centre
WHO
World Health Organisation
WSP
Water and sanitation Program
WSSC
Water Supply and Sanitation Collaborative centre
XLD
Xylose Lysine Dextrose
xiii
OPERATIONAL DEFINITIONS
Basic Sanitation - Refers to the management of human faeces at the household level.
This
terminology is used as an indicator for measuring targets of the Millennium
Development Goal on sanitation.
Household
- The basic residential unit in which economic production, consumption,
inheritance, child rearing, and shelter are organized and carried out. This may be
synonymous with family.
Hygiene -The practice of keeping oneself and surrounding environment clean.
Open defecation –Indiscriminate disposal of human waste that allows access by flies
and provides conducive environment for transmission of pathogens to human.
Sanitation -Generally refers to the provision of facilities and services for the safe
disposal of human urine and faeces.
Shared facility –Any hygiene and/or sanitation utility used by more than one household
xiv
ABSTRACT
It has been established that lack of access to safe drinking water together with
inadequate sanitation and hygiene is globally an overwhelming contributor to
approximately 4 billion cases of illness annually. In developing countries, diarrhoea
accounts for nearly 1.6 million deaths of children aged less than five years, which is
approximately 15% in all deaths for this population age group. Poor sanitation and
hygiene are among the main factors associated with diarrhoea, worm infestation, eye
and skin infections.
This study was set out to test the extent to which sanitation and hygiene promotion
influenced mothers and children’s health in Turkana District of Kenya. A
longitudinal/cohort design incorporating clustered, stratified and random sampling
methods was employed to select a sample of 300 mothers and their children aged less
than five years at baseline (2007). Interventions undertaken included capacity building
and empowerment approach to trigger communities to demand hygiene and sanitation
facilities. A post-intervention survey with the same baseline participants was carried out
in 2008.
Interviews, laboratory analysis and spot observations/inspection were used to collect
study data on demographics, socio-economic status, waste disposal parameters and
testing faecal coliform count in drinking water as well as diarrhoea related microbes in
children stool. Data were entered into the computer and analyzed using SPSS for
frequencies, descriptive and multivariate analysis.
xv
After intervention, the results showed there was significant change in sanitation and
hygiene parameters. Household ownership of traditional pit latrine increased from
45.5% in 2007 to 63.6% in 2008 (χ²=4.43, P=0.035). For hand washing practice, those
who washed hands regularly hand in Turkana District increased from 73.5% to 91.3%
(χ²=9.34, P=0.053).
Similarly, improvements in hand washing practice were observed to increase by age
group with those aged 36 and 45 years increasing significantly from 66.7% in 2007 to
88.9% in 2008 (χ²=10.01, P=0.04).
In addition, presence of soap in households
increased significantly from 65.4% to 77.9% (χ²=3.87, P=0.049) within the population
with no formal education. he mean faecal coliforms in drinking water reduced from 88
faecal coliform units in 2007 to 30.2 faecal coliform units in 2008 (P=0.005) in
Kakuma Division, 91 to 17.3 faecal coliforms units (P=0.003) in Lodwar Central, and
from 63.8 to 23.6 units (P=0.006) in Lokichogio Division.
Overall, community health outcomes before and after the intervention were
significantly improved, with comparative reduction in faecal coliform count in drinking
water ranging from 40.2% to 73.7% (P=0.003 to P=0.006) across the three Divisions
within Turkana District. Similarly, diarrhoea related microbes in children’s stool
reduced by 13% (P=0.003) while diarrhoea prevalence in children aged less than five
years reduced from 43.7% in 2007 to 30.7% in 2008 (P=001).
Promotion of hygiene and good sanitation practices in the study area improved mother’s
hygiene behaviour and child’s health with an associative strength of about 40% (Rsquare of 39.6%, P=0.048). These associated gains were strongly related to age of the
xvi
mother (P=0.015), presence of latrine (P=0.038), and reasons given at baseline for not
having latrine (P=0.005). On the other hand, multivariate analysis showed that
diarrhoea related microbes presence or absence could be predicted with an overall
precision of 92.7% with core determinants/predictors being mothers education level
(P=0.033), toilet presence (P=0.022), distance to latrine (P=0.004), source of drinking
water (P=0.019), treatment of drinking water at point of use (P=0.013), and storage
methods of drinking water (P=0.067).
In addition, the main risk factors associated with diarrhea in children aged less than five
years after intervention (2008) were strongly linked to behavioural characteristics;
namely if the child had diarrhoea at baseline (P=0.029), mother’s education (P=0.011),
latrine availability (P=0.029, latrine structure (P=0.002) and chlorine level in the
drinking water after the intervention (P=0.054).
In conclusion therefore, it is evident that promotion of improved sanitation and hygiene
using community participatory approaches such as Participatory Hygiene and Sanitation
Transformation (PHAST) in the context of community led total sanitation (CLTS) led to
significant reduction of diarrhoea prevalence in children aged less than five years and
its application should therefore be up-scaled in disadvantaged communities.
xvii
CHAPTER ONE
1.0
INTRODUCTION
1.1
Background
Turkana District has three international borders; Ethiopia to the East, South Sudan to
the North, and Uganda to the West. Nationally, it borders Samburu, Baringo and West
Pokot Districts. It is the largest District in Kenya, covering an area of 77,000 square
kilometres; and constitutes about 42% of the Rift Valley Province. It is dry and semi
arid, with less than one-third of the land mass being arable. Its population is about
860,000 people (KNBS, 2009). The topographical features include mountain ranges to
the west, open plains in the middle, and several seasonal rivers and Lake Turkana to the
east. Lake Turkana is the largest and most saline of the Rift Valley lakes.
Turkana District is classified as arid and semi-land (ASAL) and experiences prolonged
spells of inadequate water supply and limited access. As result, people walk long
distances to collect water from rivers and streams. In areas where water exists, it is
likely to be contaminated due to common use by both humans and animals. The scarcity
and low quality of water influences the level of health status in many households owing
to poor sanitation and hygiene practices, especially those related to excreta disposal and
hand washing.
1
Children especially under the age of 5 years mostly in developing countries suffer
mostly from diarrhoea, where every episode reduces calorie and nutrient uptake,
reducing growth and development for those affected. Lack of access to safe drinking
water and inadequate sanitation and hygiene practices are overwhelmingly associated
with 1.8 million deaths globally and cause approximately 4 billion cases of illness
annually (World Health Organization, 2007).
1.2
Problem Statement
Diarrhoeal diseases continue to be responsible for childhood mortality and morbidity,
primarily in developing Countries, although in the last several decades a significant
reduction on deaths from diarrhoeal diseases has been observed (Ahmed et al., 1994).
Despite advances in case management of diarrhoeal diseases, the diseases are a major
cause of morbidity and mortality among young children in developing countries (Bern
et al., 1992., Murray et al., 1994).
In developing countries, diarrhoea accounts for the deaths of nearly 1.6 million children
aged less than five years annually or almost 15% of all deaths in this segment of the
population (World Health Organization, 2003). Sanitation and human health are closely
connected as lack of appropriate hygiene policies and disposal of human excreta can
lead to transmission and spread of diseases that cause diarrhoea. Contaminated water
and indiscriminate disposal of faecal matter account for 5.7% of diarrhoea amongst
children. Poor sanitation and hygiene has been associated with diarrhoea, worm
infestation, and eye and skin infections. Out of all the sanitation and hygiene related
2
diseases, diarrhoea disease is the most deadly especially for children (Pruss, et al.,
2008).
The burden of illness for children under five years of age that arises from diarrhoeal
diseases linked to inadequate water, sanitation and hygiene is up to 240 times higher in
Africa than in high income Nations (Pruss et al., 2002). It is estimated that 94% of these
diarrhoeal cases are preventable through modification of the environment, including
interventions to increase the availability of clean water and improvement in sanitation
and hygiene (Ustun and Corvalan, 2006).
Improvement in environmental sanitation has significant positive impact on
environmentally related diseases such as malaria, diarrhoea, skin and eye infections and
the overall dignity and well-being of the populations (Harvey and Reed, 2004).
Improved access to safe water supply is attributable to reduction of diarrhoea incidences
by about one fifth and the number of deaths due to diarrhoea by more than half (Black
and Fawcett,2008a).
In many developing countries, inadequate sanitation is associated with several public
health problems and several infectious, faecal-oral -related diseases such as cholera and
diarrhoea. Over 2.2 million people die each year with more than 70% being children
under five years of age from diarrhoea related diseases (Black and Fawcett, 2008b). In
Turkana District, several outbreaks of cholera and diarrhoea diseases have previously
been reported according to Ministry of Health weekly disease outbreak reports, in May
3
2006 there was cholera outbreak in Kakuma Division of Turkana District, with 53 cases
and 2 deaths (GOK, 2006). According to (GOK, 2005) there was cholera outbreak in
Turkana District with a total of 370 cases and 7 deaths. During this period, infant
mortality rate in Turkana District was 170 per 1000 live births and child mortality rate
was 220 per 1000 live births. These rates are twice higher than the national average
78/1000 and 114/1000 respectively (KDHS, 2001). The purpose of this study therefore
is to evaluate hygiene and sanitation interventions in Turkana in reference to their
impacts on mother’s behaviour and children health.
4
1.3
Study Justification
Access to safe water and sanitation stimulates changes in hygiene behaviour, hence a
key reason for investing in hygiene and sanitation services. Starting at household level,
people are most likely at risk of contamination especially where they spend most of
their time. Health benefits are accrued to families who have latrines even where
neighbours do not; additional benefits then accrue as coverage extends to the whole
neighbourhood (IRC and WEDC, 2002).
Improved sanitation and hygiene are critical for improvement of child health through
reduction of diarrhoea, worm infestation, eye and skin infections. According to WHO
reports, more than three million children die from diarrhoea each year, and over 500
million children are infected with common worms, approximately six million people
become blind due to trachoma as a result of poor access to safe water, sanitation and
hygiene (Shordt and Caincross, 2004). Several studies have shown that improved
sanitation and hygiene promotion significantly reduce sanitation and hygiene related
diseases. Unfortunately, very few studies have been conducted to assess the
effectiveness of the sanitation and hygiene interventions in reduction of these diseases
among under privileged communities in Kenya such as those of Turkana District.
In recent past, several projects on improvement of hygiene and sanitation have been
initiated in Turkana District by the Government, NGOs, CBOs and other organizations.
However, it has been difficult to evaluate and demonstrate the effectiveness of these
5
interventions because of lack of baseline information. Majority of these projects in
Turkana District do not target sanitation and hygiene practices and the prevalence of
related diseases among children aged under five years but largely focus on the processes
and the direct outputs of the projects with little regard to actual impact on the burden of
the diarrhoea diseases. As a result, this has contributed greatly to the poor health
indicators in the District and especially among the under fives hence the need for this
study which covers both baseline and end-line data.
The results of this study will be useful to the District health managers and other public
health practitioners in the area of sanitation and hygiene, particularly in formulating
appropriate policies and strategies to address the problem of poor sanitation and
hygiene.
6
1.4
Study Questions
1.4.1
Was there any change in knowledge on sanitation and hygiene among mothers
after the interventions?
1.4.2
Did the interventions have any effect on mothers sanitation and hygiene
behaviour and practices?
1.4.3
What was the effect of the interventions on the prevalence of microbials in
drinking water at the point of use after?
1.4.4
What was the effect of the interventions on the diarrhoea prevalence among
children aged less than five years?
1.4.5
What was the effectiveness of hygiene and sanitation interventions in changing
mother’s hygiene behaviour and improving child health in Turkana District?
7
1.5
Objectives
1.5.1 Broad Objective
The aim of the study was to determine the effectiveness of sanitation and hygiene
interventions in changing mothers’ behaviour and practices and improving child health in
Turkana District.
1.5.2 Specific objectives
1.5.2.1 To assess change in sanitation and hygiene knowledge of mothers after the
interventions.
1.5.2.2 To determine the changes in sanitation and hygiene behaviour and practices of
mothers after the hygiene and sanitation interventions.
1.5.2.3 To determine the change in prevalence of microorganisms in drinking water at the
point of use after hygiene and sanitation interventions.
1.5.2.4 To determine the change in diarrhoea prevalence among children aged less than five
years after hygiene and sanitation interventions.
1.5.2.5 To determine the effectiveness of hygiene and sanitation interventions in changing
mother’s hygiene behaviour and improving child health in Turkana District.
8
1.6
Hypotheses
Null hypotheses:
1.6.1 Sanitation and hygiene interventions have no effect in changing mother’s
knowledge in sanitation and hygiene before and after the intervention.
1.6.2 Sanitation and hygiene promotion has no effect in changing mother’s behaviour and
practices after the interventions.
1.6.3 Sanitation and hygiene interventions have no effect in changing faecal coliform
count in drinking water at the point of use before and after the intervention.
1.6.4 Sanitation and hygiene interventions have no effect in changing diarrhoea
prevalence among children aged less than five years before and after the
intervention.
1.6.5 Sanitation and hygiene promotion has no effect on changing mother’s hygiene
behaviour and improving child health in Turkana District.
9
1.7
Theoretical Framework: precede-proceed model
The study applied excerpts of the Precede-Proceed model which is a framework that has
been used widely by health program planners, policy makers, and evaluators to analyze the
situation and design a health program efficiently. This model is multidimensional, founded
in the social/behavioural sciences, epidemiology, administration and education constructs.
As such, the model recognizes that health outcomes and health behaviours have multiple
causations which must be evaluated in order to assure appropriate intervention.
This planning model was initiated as a cost-benefit evaluation framework (Green, L.W.
1974). It provides a comprehensive structure for assessing health and quality of life needs
and for designing, implementing, and evaluating health promotion and other public health
programs to meet those needs. The most fundamental assumption of the model is the
active participation of its intended audience – that is, the participants will take an active
part in defining their own problems, establishing their goals, and developing their solutions.
In the case of this study participants engagement was ensured therefore this fundamental
assumption was met.
The PRECEDE model is a framework for the process of systematic development and
evaluation of health education programs. An underlying premise of this model is that health
education is dependent on voluntary cooperation and participation of the client in a process
which allows personal determination of behavioural practices; and that the degree of
change in knowledge and health practice is directly related to the degree of active
participation of the client. Therefore, in this model, appropriate health education is
10
considered to be the intervention for a properly diagnosed problem in a target population
(Green, 1992).The model can be applied in a variety of settings such as school health
education, patient education, community health education, and direct patient care settings.
PROCEED was added to the framework later in recognition of the emergence of and need
for health promotion interventions that go beyond traditional educational approaches to
changing unhealthy behaviours. The administrative diagnosis is the final planning steps to
"precede" implementation. From there "proceed" to promote the plan or policy, regulate the
environment, and organize the resources and services, as required by the plan or policy.
The components of PROCEED take the practitioner beyond educational interventions to
the political, managerial, and economic actions necessary to make social systems
environments more conducive to healthful lifestyles and a more complete state of physical,
mental and social well-being for all.
The purpose of the PRECEDE/PROCEED model is to direct initial attention to outcomes
rather than inputs. This forces planners to begin the planning from the outcome point of
view. In other words, you as a program planner begin with the desired outcome and work
backwards to determine what causes it, what precedes the outcome. Intervention is targeted
at the preceding factors that result in the outcome.
Although the study did not apply all the phases its noteworthy to understand that the
PRECEED/PROCEED model has a total of nine phases, namely: social assessment,
11
epidemiological assessment, behavioural and environmental assessment, educational and
ecological assessment, administrative and policy assessment, implementation, process
evaluation, impact evaluation and finally outcome evaluation.
Phase one to five fall under PRECEDE while phase six to nine fall under PROCEED.
PRECEDE stage of this model mainly focuses on the situational assessment surrounding a
health issue while Proceed focuses on implementation and subsequent evaluation. Phase
one and two deal with social and epidemiological assessment. Social assessment deals with
identifying the aspects in the community that impact on living healthy and productive lives,
from the community’s own perspective or felt needs. Epidemiological assessment involves
using epidemiological data to prioritise the health problems identified in the social
assessment phase.
This study focused on adopted phase three (behavioural and environmental assessment) and
four (Educational and Ecological assessment) of the Precede-Proceed model. Phase three
involves identifying behavioural and environmental correlates of a health issue. A correlate
is here defined as a factor associated with the existence of a particular health problem. This
focussed on the existence of behaviours, which have a direct relation with spread of
diarrhoeal diseases like poor hygiene practices among others. This phase also focussed on
the social environmental issues such as poverty, socio-economic disparities among sociocultural and familial control on behaviour.
12
Phase four focuses on the factors influencing the correlates identified in phase three above.
These factors are divided into Predisposing, Reinforcing and Enabling. These factors must
be changed in order to initiate and sustain the process of behaviour change. Predisposing
factors are the affective and cognitive components of behaviour. These factors can help or
hinder a person’s motivation to change.
In this study, the researcher conceptualised predisposing factors focused on; knowledge,
perception, hygiene and sanitation. Under reinforcing factors, the study focused on
community values such as cleanliness which leads to healthier environments. Enabling
factors were identifies as access to sanitation services and water. All these factors were
conceptualized based on the access to sanitation services/facilities. The Figure 1 depicts the
researcher’s concept.
Predisposing factors

Knowledge

Beliefs

Practices
Behaviour and lifestyle

Unsafe excreta disposal
practices

Negative cultural practices
Risk factors for
diarrhoea diseases
Reinforcing factors


Community values
Hygiene education
Enabling factors

Access to sanitation
services

Access to water
Social environment

Poverty

Education levels

Socio-economic differences
Figure 1: Theoretical framework based on PRECEDE-PROCEDE model
13
CHAPTER TWO
2.0
LITERATURE REVIEW
2.1
Global concern on water and sanitation impacts on health
Water supplies and sanitation were first highlighted on the development agenda about
30 years ago. This was a result of the 1977 United Nations Conference in Mar del Plata,
Argentina that recommended proclaiming the 1980s to be the International Drinking
Water Supply and Sanitation Decade with the goal of providing every person with
access to water of safe quality and adequate quantity, along with basic sanitary
facilities, by 1990” (World Water Development Programme, 2003). International water
policies and management practices have generally considered water to be a free and
renewable resource. Governments in developing countries have often subsidized water
supplies, typically in an attempt to achieve social and health benefits for low-income
households that comprise a large majority of the rural population (Lammerink, 1998.,
Whittington, 1998). Furthermore, developing countries have made huge investments in
their rural water supplies under the presumption that local communities will be involved
in their maintenance and operation. In sub-Saharan Africa, reducing the number of
people without access to safe drinking water and basic sanitation has proved to be a
significant challenge. The region is lagging behind the rest of the world with respect to
achieving the Millennium Development Goal on water supply and sanitation which
aims at reducing the proportion of people without access to safe drinking water and
14
basic sanitation by half before 2015. Kenya appears to be on track towards achieving
the water MDG while the sanitation aspect is lagging behind (WSP, 2006).
Sanitation on the other hand, generally refers to the provision of facilities and services
for the safe disposal of human urine and faeces. Inadequate sanitation is a major cause
of infectious diseases globally and improving sanitation is known to have a significant
beneficial impact on health both at household level and across communities
(www.who.int/sanitation/en, 2007). The UNESCO World report for water, (2003)
outlines the health effects emanating from poor water and sanitation as follows:

Almost half the people in the developing world have one or more of the main
diseases or infections associated with inadequate water supply and sanitation:
diarrhoea, intestinal helminth infections, dracunculiasis, schistosomiasis, and
trachoma.

More than half the hospital beds in the world are occupied by people who have
these diseases.

Eighty eight percent of diarrhoeal diseases, the second leading cause of death in
children younger than five years after respiratory illnesses are attributed to
unsafe drinking water, inadequate sanitation, and poor hygiene. Diarrhoea
morbidity is reduced by around 21% through improved water supply and by
around 37% through improved sanitation.

Though not well documented, the trauma of watching a child die from a
preventable disease such as diarrhoea as does happen in one out of five in the
15
poorest parts of the world can have lasting impacts on the psychological and
emotional health of surviving parents and siblings.

Six million people worldwide are blind because of trachoma, the leading cause
of preventable blindness and more than 150 million people need treatment.
Improving access to water and better hygiene can reduce trachoma morbidity by
27%.

Intestinal helminths (Ascaris, Trichuris, hookworm) affect hundreds of millions
of people; 133 million have high intensity intestinal helminth infections, which
often have severe consequences such as cognitive impairment, massive
dysentery, or anaemia. Safe drinking water and basic sanitation combined with
better hygiene can reduce morbidity from ascariasis, for example, by 29%.
Overall, healthy people, as opposed to those sickened by helminthiases, are
better able to derive nutritional benefit from food.

More than 160 million people are infected with schistosomes, causing tens of
thousands of deaths every year, mainly in sub-Saharan Africa. Basic sanitation
can reduce schistosomiasis by up to 77%.
16
2.2
Disease burden due to environmental hygiene and sanitation
In 400 BC, Hippocrates noted the ecological basis for disease in Airs, Waters, and
Places. In assessing the state of health across the globe, Smith et al. (1999) contend that
“many of the critical health problems in the world today cannot be solved without major
improvement in environmental quality.” A recent update of this analysis “confirms that
approximately one-quarter of the global disease burden, and more than one-third of the
burden among children, is due to modifiable environmental factors (Ustun & Corvalan
2006).
Diarrhoea continues to be one of the leading causes of death and loss of disability
adjusted life years in the developing world (Lopez et al., 2001) Estimates from the past
four decades indicate that, although there has been a decrease in mortality rates,
diarrhoeal disease-related morbidity has remained high (Kosek et al., 2003)
Interventions to reduce diarrhoea incidence generally focus on water supply, water
quality, sanitation and hygiene for all age groups, as well as breastfeeding, adequate
nutrition and immunizations specifically for children less than5 years of age. Although
there has been some attempt to utilize large-scale and widely available cross-sectional
studies such as the Demographic and Health Surveys (Gunther & Fink, 2010) in many
studies, most guidelines and policies relevant to diarrhoea in developing countries, such
as those developed by the WHO with reference to household storage or disinfection of
water, micronutrient supplementation or use of oral rehydration solution, have been
17
informed by longitudinal intervention trials that are conducted with smaller cohorts
followed over time.
According to Black and Fawcett (2008c), more than 1.2 billion people worldwide
gained access to improved sanitation between 1990 and 2004. However, even with this
progress, some 41 percent of the world’s population- an estimated 2.6 billion people,
including 980 million children lack access to proper sanitation. Lack of adequate
sanitation, poor hygiene and safe portable water are serious global health problems and
contribute to deaths of 1.5 million children under the age of five years annually due to
diarrhoeal diseases.
Although infant and child mortality rates have reduced significantly in most nations in
the recent decades, 1.5 to 2 million children still die every year from water and
sanitation related diseases (Murray et al., 2001). According to WHO (2008), an
estimated 2.2 million children aged less than 5 years die from diarrheal diseases each
year. More children are debilitated by illness, pain and discomfort primarily from
diarrhoeal diseases, intestinal worms, from various eye and skin diseases and diseases
related to insufficient and unsafe water (UNICEF, 2007). According to WHO (2007), 4
billion cases of diarrhoea occur annually, of which 88% are attribute to unsafe water
and inadequate sanitation and hygiene. Diarrhoeal diseases also account for 1.8 million
deaths every year with, the vast majority being children under five years. World Health
Organisation data on the burden of disease shows that, “approximately 3.1% of deaths
18
(1.7million) and 3.7% of disability adjusted life- years (DALYs) or equivalent to 54.2
million sufferings worldwide is attributed to unsafe water and sanitation and hygiene”.
In Africa and other developing Countries in South East Asia, 4-8% of all disease
burdens are attributable to these factors. Over 99.8% of all the deaths occur in
developing countries and 90% are deaths of children (WSSCC and WHO, 2005).
Helminthic infections are also important causes of morbidity and mortality in many
developing Countries. An estimated 1.5 billion cases of infection with Ascaris
lumbricoides, 1,200 million cases of infection with hookworm, 1,049 million cases of
infection with Trichuris trichiura, and 200–300 million cases of Schistosomiasis occur
worldwide. School age children in developing countries bear the greatest health burden
due to helminthic infections, accounting for an estimated 20% of the disability-adjusted
life years lost due to infectious diseases in children less than 14 years old (Ezeamama et
al., 2005).
According to Black and Lanata, (1995a), diarrhoeal diseases, which are frequently
transmitted by faecally-contaminated water, continue to be a leading cause of
morbidity and mortality among children in developing countries.
Improved water
supply reduces diarrhoea morbidity by 21%. While improved sanitation reduces
diarrhoea morbidity by 37.5% (WHO, 2004). Diarrhoea has been associated with up to
75% of all illnesses in young children. The risk factors include lower socio-economic
status, an unclean domestic environment, use of unsafe water, absence of soap (Sharon
19
et al., 1987). Most of the burden of diarrheal disease is thought to be preventable with
improvement in sanitation, water quality, and hygiene. However, in rural areas of low
income countries it is often prohibitively expensive to provide residents with networked
sanitation and water treatment that provide microbiologically and chemically safe water
and consistently remove faeces from the environment (Ezzati et al., 2003).
In Kenya, World Health Organization estimated that in 2002, 52% of Kenyans did not
have access to improved sanitation and in rural areas, 57% of the people lacked
sanitation coverage (WHO, 2004). About 11% of all Kenyans used flush toilets. The
most common form of sanitation facility was a pit latrine, which was used by nearly
64% of the population, while more than 16% had no facility and defecated in the brush,
field or in the open. Apart from those that do not use a latrine, 49% shared their toilet
with other households (CBS, 2004).
2.3
Notable environmental hygiene and sanitation interventions
There is a striking impact on the reduction of incidence of all cases of diarrhoea,
including dysentery and persistent diarrhoea in children less than 5 years arising from
water, sanitation and hygiene education interventions. According to a study published
by Aziz et al (1990), about 25% of children in the intervention area were experiencing
fewer episodes of diarrhoea than those in the control area. Such interventions include
general hygiene practices, hand washing, improved access to safe water supply with
advocacy being the vehicle of choice.
20
A cost-benefit analysis by Organization for Economic Co-operation and Development
Roundtable on Sustainable Development showed that achieving the global MDG target
in water and sanitation would bring substantial economic gains from both health and
other benefits: each US$1 invested would yield an economic return of between $3 and
$34, depending on region. The benefits would include an average global reduction of
diarrhoeal episodes of around 10%. If the goal for water and sanitation were met, the
health-related costs avoided would reach $7·3 billion per year, and the annual global
value of adult working days gained as a result of less illness would be almost $750
million. Improvement in sanitation, hygiene, and water contributes to improved health,
generates savings for households and national health budgets, and contributes to poor
households' economies through reduced costs and losses of time. Saving time may
enable productive activity and school attendance, especially for girls. Investment in
water and sanitation whether through development assistance at the national or
community levels or by poor households themselves—makes sound economic sense
(OECD and ADB, 2004)
21
2.3.1
General Hygiene Practices
Improved personal and environmental hygiene reduce infections and reduces the spread
of infections (Aiello and Larson, 2002). Thus appropriate hygiene practices are
necessary for maintaining good health. The function of hygienic behaviour is to prevent
the transmission of the agents of infection. Impact of several environmental sanitation
conditions and hygiene practices on occurrence of diarrhoea among children under five
years was associated with washing and purifying fruit and vegetables; domestic water
reservoir conditions; faeces disposal, presence of vectors in the house and flooding in
the lot (Heller et al., 2003).
Sanitation and hygiene, given their direct impact on infectious disease, especially
diarrhoea, are important for prevention of malnutrition. According to WHO/UNICEF
(2010), improved sanitation include use of flush toilet, ventilated pit latrine, pit latrine
with slab and compositing toilet whereas unimproved pit latrine are shared toilet
facilities, no facilities, pit latrine without a slab and bucket. In their assessment they
found out that access to toilet/latrine facility was by 48.3% of the households. Of the
51.7% who did not access a toilet facility, they used the bush, open land, laga or near a
river. These results are not significantly different from the 2010 findings in a study done
in Marsabit where 44.6% of the households had access to toilet facilities. Of the
caregivers, less than half, 42.6% disposed of the child’s stool immediately and
hygienically while 38.7% disposed the child’s stool in the bush and 18.7% did not
22
dispose the child’s stool. The unhygienic practices of stool disposal predispose children
to diseases such as diarrhoea.
Approximately 80 percent of the hospital attendance in Kenya is due to preventable
diseases. About 50 percent of these illnesses are water, sanitation, and hygiene related.
In 1999 alone, more than 2,500 Kenyans died from diarrhoea and related diseases.
Diarrhoea and gastroenteritis were the highest causes of infant hospitalization in 1999.
These diseases are a result of poor hygiene and unsanitary living conditions, which
could be prevented by instituting appropriate sanitation and hygiene practices (GOK,
2007).
2.3.2
Hand washing
Hygiene related practices such as the safe disposal of faecal material and hand washing
after contact with faecal material could reduce the rates of intestinal infection
considerably (Astier et al., 1997). Hand washing efficacy studies carried out in the form
of randomized controlled trials and the outcome interests have shown health related
benefits (Luby et al., 2005). Different field friendly methods of evaluations can also
now be used.
Data on hand washing can be inferred, observed or reported. Observed data is
considered the most objective data available for measuring hand washing behaviour.
Observations may be conducted using spot checks or continuous observation. Reduced
23
hand contamination has been demonstrated among persons exposed to hand washing
promotion or persons specifically instructed to wash hands with a cleansing agent,
compared to persons who were not exposed (Hoque et al., 1995). Presumably the level
of hand contamination at critical times, such as preparing food or feeding a young child
impacts the degree to which pathogens are transmitted at those times.
In terms of measuring contamination that is relevant to pathogen transmission, it would
necessitate collection of samples at those critical times, after defecation, before eating
and food handling. In addition, testing for the presence of and quantification of faecal
coliforms including the Escherichia coli on the subject stool using microbiologic test
may be considered an inferred data on the overall hygienic practice including, hand
washing behaviour (Kaltenthaler and Pinfold, 1995).
Hand washing with soap and water can reduce diarrhoeal diseases by 35% or more.
Safe disposal of faecal material serves as primarily intervention to prevent faeces from
contaminating the environment. It is particularly important to isolate the faeces of
people with diarrhoea, most of whom are usually young children. Pit latrines, when
used by adults and for the disposal of young children’s faeces can reduce diarrhoea by
36% or more (Astier et al., 1997). A study done in Bangladesh confirmed the
importance of hand washing and compound cleanliness in reducing diarrhoeal diseases
among mothers with small children. In this study, soap was supplied to sixty five
mothers who were encouraged to wash their hands after, defecation before eating and
24
food handling. They were also encouraged to clean children excreta around their homes
promptly and then dispose it into pit latrines or bury it properly and then wash their
hands with soap and water. A marked decline of diarrhoea was observed (Gracey,
1993).
The most effective way of preventing diarrhoeal diseases is to prevent faecal material
from getting into the child’s environment by safe disposal of faeces and washing hands
with soap once faecal material has contaminated them. Hand-washing interrupts the
transmission of disease agents and so can significantly reduce diarrhoea and respiratory
infections, as well as skin infections and trachoma.
A recent review (Curtis and Cairncross, 2003) suggests that hand-washing with soap,
particularly after contact with faeces (post-defecation and after handling a child’s stool),
can reduce diarrhoeal incidence by 42-47 percent, while a publication by Rabie and
Curtis (2006) suggests a 30 percent reduction in respiratory infections is possible
through hand-washing. This remains true even in areas with high faecal contamination
and poor sanitation. They further demonstrated effectiveness of hand washing in
reducing respiratory infection risk by 16%. A recent study shows that hand washing
with soap by birth attendants and mothers significantly increased newborn survival rates
by up to 44 per cent (Rhee et al., 2008)
25
Another recent study found that children under 15 years living in households that
received hand-washing promotion and soap had half the diarrhoeal rates as children
living in control neighborhoods (Luby et al., 2004). Because hand washing can prevent
the transmission of a variety of pathogens, it is said to be more effective than the use of
any single vaccine in disease prevention. Promoted on a wide-enough scale, hand
washing with soap could be thought of as a ‘do-it-yourself’ vaccine. A study by Bowen
et al, (2007), suggests that hand washing promotion in schools can play a role in
reducing absenteeism among primary school children. In China, for example, promotion
and distribution of soap in primary schools resulted in 54 per cent fewer days of
absence among students compared to schools without such an intervention.
Habits are ingrained and sustained behaviours, often developed in childhood. Research
has shown that once people anywhere acquire ingrained and habitual behaviours, they
are not easily lost. The task for hand-washing promotion is not to achieve a single handwashing event, but to instil a routine and sustained habit that happens automatically
with every contaminating event. While habits are often learned at an early age, there are
opportunities for change, especially at life-changing events. Many mothers report that
hand hygiene did not become important to them until a baby was born and that if
midwives or others involved with peri-natal care recommended hand washing with
soap, it would likely take hold.
26
Another life-changing event for many mothers is moving to the husband’s home after
marriage and learning the habits of the new household. Drivers are innate and learned
modules in the brain that motivate particular behaviours. They come in the form of
emotions and the feelings that people report when carrying out particular behaviours.
Discovering drivers is the key to successful promotion of hand washing. As with risk
practices, determining drivers can be difficult because they may be buried in the
subconscious where as much as 95 percent of human thought takes place (Zaltman,
2003. There may be perceptions of shame or embarrassment in reporting them, for
example, using soap to heighten sexual attractiveness. Notably, hand washing success is
attributable to high level of political commitment, state or Division level action and
community mobilization by village level authorities.
2.3.3
Improved access to safe water supply
A silent humanitarian crisis kills some 3900 children every day and thwarts progress
towards all the Millennium Development Goals (MDGs), especially in Africa and Asia.
The root of this unrelenting catastrophe lies in these plain, grim facts: four of every ten
people in the world do not have access to even a simple pit latrine; and nearly two in ten
have no source of safe drinking water (WHO, 2004)
Presence of improved sanitation and hygiene practices, supplemented with satisfactory
supply of water is essential for improved life with tangible benefits to health. Access to
safe drinking water is essential to health. As a basic human right and a component of
27
effective policy for health protection, investments in the water supply and sanitation can
yield a net economic gain (UN-HABITAT, 2003).
Knowledge on disease transmission suggests that 100% of infections caused by soiltransmitted helminthes can be prevented by adequate water, sanitation and hygiene
(WHO, 2007). Evidence indicates that lack of safe water increases the prevalence of
microbial hazards and continues to be a primary concern in both developing and
developed Countries. A report by WHO (2006) indicated that the greatest disease
causing microbial risk is associated with ingestion of water contaminated with human or
animal (including bird) faeces. Faeces are a major source of pathogenic bacteria,
viruses, protozoa and helminthes and faecal derived pathogens form principal concern
in setting health-based targets for microbial safety. Microbial contamination of drinking
water contributes to disease outbreaks and to emergence of diseases in developed and
developing Countries. Control of waterborne diseases is an important element of public
health policy and objective of water supplies (WleChevallier and Kwock-Keug, 2004).
According to WHO analysis, faecal indicator bacteria provide a sensitive measure of
pollution of drinking water supplies. Verification of the microbial quality of drinking
water includes testing for Escherichia coli as an indicator of faecal pollution. E. coli
provides conclusive evidence of recent faecal pollution. In practice, testing for thermo
tolerant coliform bacteria can be acceptable alternative in many circumstances (WHO,
2006).
28
In Kenya, Access to safe water was estimated at 89.7% in urban areas and 43.5% in
rural areas, or a national average of about 57% (as reported in the 2000 Multiple
Indicator Cluster Survey). In addition, about 81% of the population had access to safe
sanitary means, with 94.8% in urban areas and 76.6% in the rural areas. The World
Bank’s 2004 Water and Sanitation Country Assessment had put the coverage at 49% for
water supply (urban 86% and rural 31%) and 86% for sanitation (urban 96% and rural
81%). Among the main synergies between the water and sanitation sector (WSS) sector
and other MDGs were reduced incidence of water-borne diseases, empowerment of
women and girls through savings on time and energy especially in provision of water,
improvement in the living conditions in slum areas, business opportunities in the
envisaged private sector participation (especially for women entrepreneurs in water and
sanitation service delivery), and higher retention of girls in school due to improved
provision of water and sanitation facilities (CBS, 2003)
2.4
Effectiveness of WASH interventions in Reducing Diarrhoea
Morbidity
Diarrhoeal diseases, which are frequently transmitted by faecally-contaminated water,
continue to be a leading cause of morbidity and mortality among children in developing
countries (Black and Lanata, 1995b). According to WHO 2004 fact sheets, 1.8 million
people die every year from diarrhoeal diseases (including cholera) of which 90% are
children under 5, mostly in developing countries. Accordingly, 88% of diarrhoeal
disease is attributed to unsafe water supply and inadequate sanitation and hygiene. For
29
a while now, it has been widely accepted that water supplies and sanitation, though
necessary for the prevention of diarrhoeal diseases in young children, are not sufficient
by themselves unless they are accompanied by changes in domestic hygiene behaviour
(Mertens et al., 1992., Cairncross, 1990).In the lancet Series on Maternal and Child
Under nutrition Bhutta et al (2008) states that of several disease prevention strategies
that reduce the burden of infections (and hence affect nutritional status), hygiene
interventions (hand washing, water quality treatment, sanitation and hygiene) are
among the core interventions to affect nutritional status.
Previous studies have reported the results of interventions to reduce illness through
improvements in drinking water, sanitation facilities, and hygiene practices in less
developed countries. One of the initial systematic review and meta-analysis (Lorna et
al., 2005) comparing the evidence of the relative effectiveness of these interventions
reported that all the interventions studied were found to significantly reduce the risks of
diarrhoeal illness. The relative risk estimates from the overall meta-analyses ranged
between 0·63 and 0·75. The results showed that multiple interventions (consisting of
combined water, sanitation and hygiene measures) were not more effective than
interventions with a single focus.
A meta-analyses by Curtis and Cairncross (2003) examined the impact of hand-washing
on diarrhoea risk and found a reduced risk of 50 per cent (Aiello et al., 2008), a reduced
risk of gastrointestinal illness of 34 per cent across 12 studies conducted in developing
30
countries and also found a reduced diarrhoea risk of one-third across five randomizedcontrolled trials (RCTs) in developing countries.
A recent meta-analysis (Waddington et al., 2009) has combined the results of various
analyses and reviews conducted in the recent past and have pooled the respective
results. The results confirm the conclusion of earlier reviews that the three most
effective interventions to reduce diarrhoea morbidity in children under 5 are hand
washing with soap (37%), improved sanitation (34%) and point of use (POU) water
treatment (29%).
One reason for the relatively low effectiveness of source water
treatment interventions (21% in the chart below) is the risk of microbiological
contamination of drinking water during collection and storage in the home (Clasen et
al., 2006). A systematic meta-analysis of 22 studies measuring bacteria counts for
sources of water supplies and stored water in the home concluded that approximately
half of the included studies identified significant contamination of water after collection
(Wright et al., 2004).
According to Luby et al.(2007) and colleagues who studied hand washing behaviour in
347 households from 50 villages across rural Bangladesh. The researchers compared a
non-intervention control group with communities that were part of a large hand
washing, hygiene/sanitation, and water quality improvement programme — Sanitation,
Hygiene Education and Water Supply in Bangladesh (SHEWA-B), organised and
supported by the Bangladesh Government, UNICEF, and the UK’s Department for
31
International Development (DFID,1998). The following are the results of their study.
The following are the results of their study showing Reduction in diarrhoea morbidity in
children aged <5 years as per intervention
Source: (Waddington et al., 2009)
Figure 2: Effectiveness of WASH Interventions to reduce diarrhoea morbidity in children
aged less than 5 yrs
They concluded that washing of hands with soap, or simply rinsing hands without soap
prior to preparation of food can reduce the occurrence of diarrhoea in children.
32
2.5
Role of advocacy as a software approach in hygiene and sanitation
promotion
The World Health Organisation and the United Nations Children Fund Joint Monitoring
Programme (JMP) for water and sanitation estimate that despite the huge efforts to
increase access to sanitation, over 700 million people are forced to defecate in the open
(WHO/UNICEF-JMP, 2008). Furthermore, a recent assessment of the existing evidence
suggest that poor sanitation may be linked to as much as a quarter of all the under five
deaths (Cumming, 2008).
Advocacy and promotion on sanitation and hygiene contributes to a significant increase
in access to sanitary means of excreta disposal and reduced disease burden,
(Bajracharya, 2003). A study in Mpande and Bukalimo villages in Uganda reported an
increase in construction of traditional latrines by 80.9% and 87.8% respectively after
intervention (Narathius et al., 1994).
Multi- level efforts such as media, planning workshops, training sessions and house-tohouse visits by village authorities and health officials raised greater awareness of
sanitation and hygiene issues and led to construction of latrines on a self-help basis
(Bajracharya, 2003). The study underscores the importance of advocacy, health
education and promotion in improvement of hygiene practice (Gilman et al., 1993,
Bajracharya 2003).
33
Hygienic behaviour in some cases is determined by beliefs that run counter to
biomedical knowledge. In urban Karachi, Pakistan, for instance, infant diarrhoea was
frequently considered to be related to teething or weather and thus was considered a
normal event (Quareshi and Lobo, 1994). In 2003, UN-HABITAT identified a range of
behaviours that could facilitate transmission of diarrhoea diseases including cholera and
taeniasis. Therefore, knowledge on transmission routes of diarrhoea diseases and
sources of infections was found to reduce oral-faecal infections (Halvorson, 2004).
34
CHAPTER THREE
3.0
METHODS AND MATERIALS
3.1
Study Area
The study was conducted in Lokichoggio, Kakuma and Central Divisions of Turkana
District. The three Divisions were purposively selected as the Ministry of Health and
UNICEF had planned to implement a sanitation and hygiene programme in these areas.
A map of the referenced areas is provided in appendix 4.
3.2
Study population
The study participants were mothers living in the three Divisions who had children aged
less than five years.
3.3
Inclusion/Exclusion criteria
A household with children of five years of age and below, mothers living in the selected
Divisions who consented to participate in the study after having being identified using
the randomized selection. Any person who did not meet the criteria was not involved in
the study.
3.4
Ethical Issues
Prior to data collection, clearance was obtained from the National Council for Science
and Technology, Ethics and Research Review Committee of Ministry of Health. The
District Medical Officer of Health in Turkana District (appendix 5) was also informed
and permission sought. The purpose of the study was explained to the participants in the
Turkana language before seeking their consent. Participants were treated with respect
35
and dignity and informed of their rights to withdraw at any stage of the interview. The
participants were assured that all the information given would be kept confidential and
used only for the purpose of the study and no names were required. All the participants
were informed that there was no unforeseen risk, pain or discomfort to be occasioned
participation in the study and neither the relatives nor partners would suffer the same.
Community leaders were consulted in the whole process of data collection and to
further involve the communities.
Respondents were informed that there was no direct benefit to be accrued and there was
no money to be paid for participating in the study. However, their participation would
generate knowledge which could be used for the general benefit of the public and
especially their community.
3.5
Study design
The study adopted a longitudinal/cohort design. This design was chosen because a
control or comparison condition could not be found neither was it desirable. For each
participating household, baseline measures were taken two months before the
interventions and end line measures taken two months to the end of the one year
interventions.
The intervention entailed distribution of 6,150 water filters and PUR sachets to 10,000
households for home based water treatment and development of the capacities of
36
women as duty bearers to create awareness, knowledge and demand for the water filters
and ensure that safe water is used in households to reduce environmental risks to
children health. TOTs were trained on Participatory Hygiene and Sanitation
Transformation (PHAST) coupled with Community Led Total Sanitation (CLTS)
combined with animated video. Upon completion of the training, the TOTs were given
the PHAST training tools to enable them carry out sensitization at household levels.
They used audio-visual shows blended with CLTS to ignite community dialogue among
the people. The process also involved the production of culture-specific participatory
training tools and videos tailored with appropriate messages.
3.6
Sample size determination
The formula by Lemeshow et al., (1990) used in WHO health related studies was
employed to determine the required sample size for this study.
n=/2 P (1-P) P1 (1- P1 ) P2 (1- P2 )2
(P1-P2) 2
Where;
n = Population sample
P= P1 P2
; Pooled proportion of disease (diarrhoea)
2
/2 = 1.96
; Significance level, 0.05
= 95 % CL =1.28
; Study power
1-P= Proportion without disease
37
P1= Baseline diarrhoea prevalence, where from previous studies it is estimated at 25%
P2 = Post intervention diarrhoea prevalence estimated at 12.5%, assuming that the
intervention will reduce diarrhoea prevalence by 50%. This gave a minimum sample
size of approximately 140. Considering a maximum design effect of 2, this gave a
sample size of (1402) = 280.This was approximated to 300.
3.7
Population Sampling Procedure
A comprehensive sampling frame was required from where the sample would be drawn.
In this study the Primary Sampling Unit (PSU) was the Central Bureau of Statistics
(CBS) Enumeration Area (EA)1, which was taken as cluster. The Eas have maps
showing the boundaries and structures as well as total households and population by sex
as per the 1999 Housing and Population Census. In order to have updated details and
representative sampling frame, a listing exercise was done. The listing involved
updating the number of households, numbering the structures and updating the age
composition of the household. After the listing exercise, the sampling interval for the
Division was then determined and a filter done to include in the sample only the
households with women having children less than 5 years of age. A total of 30 clusters
in all the 3 Divisions were selected for study using the systematic Probability
Proportional to Size (SPPS) sampling method.
1 For ease of carrying out the 1999 Housing and population Census, CBS created small non-overlapping units called
Enumeration Areas (EAs), from each of the sub location, which were defined according to a specified measure of
size (MoS).
38
3.8
Data collection methods
3.8.1
Field Questionnaire
Research assistants were recruited with consideration given to those who had completed
twelve years of formal education and were conversant in English and Turkana
language. Research assistants were given a two day’s training on the data collection
tools and pre-tested a few questions. Results of the pre-testing exercise were discussed
and corrections incorporated in the questionnaire.
A household survey was carried out before and after interventions based on a structured
household questionnaire and observations. The spot checks were made on structural
elements around the homesteads to determine hand washing behaviours particularly use
of soap during hand-washing. The key indicators used to determine hand-washing
behaviour among: respondents were; dedicated hand washing station, use of soap for
washing hands, proportion of respondents who reported washing of their hands during
the critical junctures and percent of care givers who reported washing hands with soap
during most times that hands are washed. These indicators were used to collect
information on hygienic behaviour and practices. On gauging changes in knowledge,
structured questions were asked on two parameters; importance of latrine use and
knowledge of diseases associated with use of contaminated water prior and after the
intervention. Correct response was treated to mean that the person was knowledgeable
on the subject matter.
39
3.8.2
Laboratory specimen processing
1.
Water Quality Assessment Procedure
Water samples were taken at the point of use in the households for further examination
in the laboratory for chlorine level and presence or absence of faecal coliforms. The
levels of chlorine were detected using DPD complex tablets. The DPD tablets
dissociated if any chlorine compounds were present in the sample. The samples were
analysed for chlorine levels using calorimetric machine from which the chlorine optical
density (OD) in the sample was taken and recorded. The calorimeter was calibrated
using pure water with zero traces of chlorine and chlorine level of less than 0.2 mg/l
was regarded as low and in-effective while chlorine levels of more than 0.2 mg/l was
regarded as effective in protecting the water from bacterial contamination.
Bacterial contamination was detected by presence or absence of faecal coliforms using
Filter Membrane Technique. One hundred millilitres (100 ml) of water sample was
filtered through a membrane filter embedded with media. The membrane was then
cultured on a pad of sterile selective broth containing an indicator. After incubation, the
number of coliforms colonies was counted. This gave approximate number of E.coli in
One hundred millilitres (100 ml) of water. Detailed description of Filter Membrane
Technique is as outlined in the next sub-section below.
Water microbiological assessment Procedure using Filter Membrane Technique
40
Water microbiological analysis was done by determining the Total Coliforms(TC) and
Escherichia coli(EC) by Membrane Filtration using a simultaneous detection
technique(MI Medium) as described by Brenner et al 1993.This is a method that
describes a sensitive and differential membrane filter (MF) medium using MI agar or
MI broth for the simultaneous detection and enumeration of both total coliforms (TC)
and Escherichia coli (E. coli) in water samples in 24 hours on the basis of their specific
enzyme activities. Two enzyme substrates, the fluorogen 4-Methylumbelliferyl–βDgalactopyranoside (MUGal) and a chromogen Indoxyl- β –D-glucuronide (IBDG), are
included in the medium to detect the enzymes β-galactosidase and β –glucuronidase
respectively produced by TC and E. coli, respectively.
Briefly, 100ml of Water samples were collected in sterile polypropylene sample
containers with leak proof lids and filtered through a 47-mm, 0.45-µm pore size
cellulose ester membrane filter that retains the bacteria present in the sample. The filter
was then placed on an absorbent pad saturated with 2-3mL of MI broth and the plate
incubated at 35°C for up to 24 hours. The bacterial colonies that grow on the plate were
inspected for the presence of blue color from the breakdown of IBDG by the E. coli
enzyme β –glucuronidase and fluorescence under longwave ultraviolet light (366 nm)
from the breakdown of MUGal by the TC enzyme β –galactosidase. The total E.coli and
TC counts Per ml of the water sample was then determined according to the guidelines
of the Microbiology Manual described by Bordner et al 1978.
41
Stool microbiological analysis
The mothers and guardians were requested to collect stool specimen from their children
aged less than five years for analysis. Laboratory investigations for sanitation and
hygiene related diseases were carried out. The stool specimens were examined for
presence or absence of diarrhoea causing agents such as E.coli, Salmonella and
Shigella, through procedure and techniques described by Cheesbrough (2000).
On arrival in the laboratory, the stool samples collected from the field were examined
carefully and noted the consistency of the specimens, including the following; the
colour of the stool, whether the stool was formed or semi- formed, uniformed or fluid
and the contents (i.e. blood, mucus or pus)
Stool microscopy for ova and cysts
All stool samples were tested for the presence or absence of intestinal helminths and
protozoa using direct faecal smears (saline and iodine mount preparation) as described
Cheesbrough (2000).
Briefly, the stool samples were appropriately labelled in order to match with laboratory
number of the subjects. A drop of saline was put on the center of the left half slide and a
drop of iodine was placed in the center of the right half of the slide; then with an
applicator stick, a small portion of the faeces (approx. 2g) which is about the size of the
match stick head was added to the drop of iodide, and mix with the faeces to form a
suspension ;then this was covered with a cover slip, after which the preparation were
42
examined using the ×10 objective or if needed for identification by using higher power
in a systematic manner so that the entire area is observed. When organisms were seen,
one may switch to a higher magnification to see a more detailed morphology of the
object in question.
Stool Culture, isolation and identification of pathogens
Processing of stool specimens
The isolation of enteric pathogens was done as described by Ewing and Edwards
(1986). Briefly, stool specimens were cultured for salmonella Shigella and E. Coli spp
in Xylose lysine dextrose (XLD), Salmonella shigella medium (SS) and MacConkey
agar (Difco Laboratories, Detroit, Mich.). Stool culture for vibrio spp was done on
Thisulphite citrate bile salts agar(TCBS) medium.
Enrichment for Shigella,salmonella and E.coli
was performed by culturing the
specimens into selenite F broth (Oxoid, UK) while that for vibrio was done on Alkaline
peptone water(APW). All the inoculated culture media were incubated at 37°C for 24
hours. The selenite F broth and APW were then sub cultured onto SS,XLD and
MacConkey agar plates and TCBS respectively and incubated as described above. The
agar plates were examined colonies presenting as non lactose fermenters and non
hydrogen
actose
(H2S) gas producers. These characteristics are used to distinguish
43
e.coli,salmonella and Shigella spp from each other. The
actose fermenters colonies
from TCBS were selected as suspect vibrio spp.
Identification of pathogens
Biotyping with test tube media
Biochemical identification of the enteric bacterial pathogens was done using Triple
sugar iron agar (Oxoid, UK),Lysine indole motility medium(Oxoid, UK),Simmons
citrate (Oxoid, UK),Methyl Red-Vogues Proskeur medium(MR-VP)(Oxoid, UK) and
Urea agar (Oxoid, UK).The tests were performed as described in the clinical
microbiology procedures handbook (Isenberg,1992). In addition string test and catalase
test were performed for identification of vibrio cholera spp. The identity of the
respective pathogens was done based on their specific reactions in the above
biochemical media as shown in the chart (Appendix 3).
Biochemical identification by serotyping
The identity of the pathogens was confirmed by serotyping the colonies using the
genius/type specific antisera (Oxoid, UK) according to manufacturer instructions.
44
3.9
Data Management and analysis
The quantitative data was entered into SPSS version 17.0. Frequencies were run and then data
cleaning was done. For qualitative data, the tapes were transcribed then content analysis
(identifying, coding, and categorizing the primary patterns in the data) was then done. Actual
analysis involved calculation of case prevalence, independence tests and goodness of fit using χ2
test and associations using regression lines; these tests are as detailed below;
For those variables with nominal or ordinal scale, the chi-square goodness of fit test was
applied to ascertain the significance of any observed changes between 2007 (baseline)
and 2008 (post-intervention). The null hypothesis for this test is that there was no
difference in the observed proportions within the two periods (similar).
For tables with two rows and two columns, Pearson chi-square, the likelihood-ratio chisquare, Fisher’s Exact test, and Yates’ corrected Chi-square (continuity correction) were
applied. For 2 × 2 tables, Fisher’s Exact Test was computed when a table that does not
result from missing rows or columns in a larger table has a cell with an expected
frequency of less than 5. Yates’ corrected chi-square was computed for all other 2×2
tables. For tables with any number of rows and columns, it is understood that when both
table variables are quantitative, Chi-square yields the linear-by-linear association test.
45
For variables with continuous data, Student’s t-test was used to compare sample means
by calculating Student’s t and display the two-tailed probability of the difference
between the means.
Overall measurement of association between the independent variable (core outcome)
namely, chlorine level in mg/l and faecal coli forms in 100mls with key dependent
variables (modifiable risks targeted during intervention was ascertained through logistic
regression modeling.
3.10
Study Limitations
From literature, it is indicated that evaluation of handwashing practices should best be
observed, however, this was not possible in this study since the population is sparsely
distributed and therefore self-reported information was gathered.
There could also have been Hawthorns effect due to the fact that the households had
been visited at baseline and a repeat survey was done at end line (within 1 year).
In addition, Turkana District is an ASAL area and water is scarce, limiting water
availability for hand washing.
46
CHAPTER FOUR
4.0
RESULTS
4.1
General overview
A total of 300 respondents interviewed at baseline (2007) were followed up and reinterviewed at end-line (2008). All of them were mothers with children aged less than
five years as stated in the inclusion criteria. Their demographic and distribution
characteristics are as outlined in subsequent sub-sections.
4.2
Key Demographic Variables
This sub-section covers the core demographic variables relevant to this study. Figure 3
shows the overall distribution of respondents across the three Divisions of Turkana
District: -
4.2.1
Distribution of Respondents by Division
Notably, Lodwar Central Division had the highest proportion of respondents at 46.7%
(n=140) whereas Kakuma and Lokichogio had equal proportion of respondents each at
26.7% (n=80).
47
Figure 3: Distribution of Respondents by Division
The respondent distribution was proportional to the population density in each of the
three Divisions.
48
4.2.2
Distribution of Respondents by Age
High proportion of respondents (36.3%) were aged between 26 and 35 years, followed
by those aged between 14 and 25 years (26.3%) and the rest were aged above 36 year.
The age distribution of the respondents is as shown in Figure 4.
Figure 4: Age distribution of study respondents
Overall, respondents aged between 26-35 years formed the majority of the sampled
population in all the three Divisions except in Kakuma where those aged over 46 years
formed a slightly higher proportion (24%). Figure 5 shows age distribution of
respondents across the three Divisions.
49
Respondent's age distribution by
Division
100%
> 46 yrs
36-45 yrs
26-35 yrs
14-25 yrs
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Kakuma
Lodwar
Central
Lokichogio
Figure 5: Respondent’s Age Distribution by Division
Notably, the observed differences in age distribution of respondents across the three
Divisions were significant (P=0.003). This shows that there is potential of masking
inter-divisional differences and confounding if data segregation by Division and age
group is not considered during analysis.
4.2.3
Education level of Respondents
Regarding education level of the respondents, out of the 300 interviewees, the highest
proportion (43%) had primary level education followed by those with no education
(35%) whereas 22% had post-primary education. This is depicted in Figure 6: -
50
Figure 6: Highest Education Level of the Respondent
In addition, the proportions on education level were however different across the
Divisions. For Kakuma, majority 39 (49%) had primary education, 24 (30%) had no
education, while 17 (21%) had post-primary education. For Lodwar central, majority 67
(48%) had primary education, 50 (36%) had no education, while 23 (16%) had postprimary education. For Lokichogio, majority 31 (39%) had no formal education, 26
(33%) had post-primary education, while 23 (29%) had primary education. This is as
shown in Figure 7: -
51
Distribution of Respondent’s Level of Education by
Division
100%
80%
60%
40%
20%
0%
Kakuma
No Formal
Education
Lodwar Central
Primary
Lokichogio
Post-primary
Figure 7: Distribution of Respondent’s Level of Education by Division
These observed differences in distribution of education level of respondents across the
three Divisions were significant (P=0.017), hence not attributable to chance. This shows
that there is potential of masking inter-regional differences and confounding if data
segregation by Division and level of education is not considered during analysis.
4.2.4
Latrine Distribution by Division
Latrine structure and distribution across the three Divisions was only checked at
baseline and classified as either temporary or permanent based on material used for the
super-structure. Out of the 243 (81%) of households with latrine, it was noted that
majority (54.7%) were temporary. Within the Divisions, Lokichogio had the highest
proportion of temporary latrines at 58% (39), followed by Lodwar central having 56%
52
(67) and then Kakuma with 48% (27). The alternative proportions represent permanent
latrine structures as shown in Figure 8: -
Distribution of Latrine Type by Division
100%
Proportion (%)
80%
27
67
39
53
28
Lodw ar Central
Lokichogio
60%
40%
20%
29
0%
Kakuma
Permanent
Temporary
Figure 8: Distribution of Latrine Type by Division
Notably, the observed differences in distribution of latrine structure by Division were
not statistically significant (P=0.51).
The study also sought to highlight the factors that affect provision of toilets at
household level. For those households without toilet facilities at baseline (19%), the
main reasons for not having a toilet in the household level were geophysical and
economic constraints to construct (51.7%) followed by availability of a bush hence
pointed that they did not need one (48.3%). The trend and reasons did not change after
53
the intervention (P=0.242) as geophysical and affordability was still identified as the
main set back to having a toilet in the households. This is as detailed in Table 1: -
Table 1: Reason for not having toilet facility (2007 and 2008)
Reasons for no toilet
facility at baseline
(2007)
geophysical and
economic constraints
Do not need one
Total
Reasons for no toilet facility
after intervention (2008)
geophysical &
economic
Do not need
constraint
one
Total
36.4% (104) 15.4% (44) 51.7% (148)
(30.8%) 88
67% (192)
17.5% (50) 48.3% (138)
32.9% (94) 100% (286)
X 2=1.368; P=0.242
4.3
Knowledge and Practices of Sanitation and Hygiene Before and After
Intervention
This part considered changes in latrine management, drinking water handling methods
and hand-washing practices among mothers before and after the intervention.
4.3.1
Change in Knowledge of latrine importance
There was a slight increase in the proportion of population that regarded latrines as
important from 70% in 2007 to 80.2% in 2008. This noted change was not of statistical
significance (χ2 =1.196 P=0.274). The breakdown in Table 2;
54
Table 2: Cross-tabulation of whether latrine is important in 2007 and in 2008
2007
2008
χ2
P-value
Is latrine important Count (% of Total) Count (% of Total)
Yes
205 (70%)
235 (80.2%)
1.196 0.274
No
88 (30%)
58 (19.8%)
Regarding change in latrine importance, those who associated latrine with reduction
in diseases increased from 44.3% to 62.3%.
The study expectation was that
respondents would associate latrines with disease prevention which was the focus of
sanitation promotion. The noted change was of no statistical significant (χ2 =8.588,
P=0.476) and details are as outlined in the Figure 9: -
Figure 9: Distribution of knowledge on latrine importance (2007 and 2008)
Regarding change in knowledge on diseases associated with drinking contaminated
water, it was noted that knowledge on typhoid increased from 8.7% in 2007 to 44.2%,
55
cholera from 27.3% to 37.7%. More over that of general diarrhoeal diseases reduced
from 20.3% to 6.1% owing to the enhanced awareness that diarrhoea diseases are not
necessarily due to unsafe water but to general hygiene and sanitation factors including
hand washing with soap. The overall change was however not statistically significant
(P=18.7, χ2=.768), details are as shown in Table 3: -
Table 3: Knowledge on diseases associated with drinking unsafe water
Disease associated with unsafe water (2008)
Typhoid
Diseases
Typhoid
associated with
unsafe water
Cholera
(2007)
Total
4.3.2
Cholera
10 (4.3%) 6 (2.6%)
28 (12.1%)
intestin
al
worms Diarrhoea Malaria
1 1 (0.4%)
(0.4%)
URTI
1 (0.4%)
24
2 6 (2.6%) 1 (0.4%)
(10.4%) (0.9%)
1
(0.4%)
HIV/AI
DS
Total
0 20 (8.7%)
1
1
63 (27.3%)
(0.4%) (0.4%)
intestinal
worms
33 (14.3%) 23 (10%)
2 3 (1.3%)
(0.9%)
3 (1.3%)
1
2
(0.4%) (0.9%)
Diarrhoe
a
22 (9.5%) 20 (8.7%)
1 1 (0.4%)
(0.4%)
2 (0.9%)
1
(0.4%)
0 47 (20.3%)
Malaria
9 (3.9%) 14 (6.1%)
3 3 (1.3%)
(1.3%)
4 (1.7%)
1
(0.4%)
0 34 (14.7%)
102 (44.2%)
67 (29%)
87
9 14 (6.1%) 11 (4.8%)
5
3
(37.7%) (3.9%)
(2.2%) (1.3%)
Change in hand washing practice
Washing of hands in the three universally accepted critical times, namely; after visiting
a toilet, before cooking and before eating was also evaluated. Regarding change in hand
washing practice in Turkana District, those who wash hands regularly increased from
73.5% to 91.3%. The detailed distribution is as shown in the Table 4: -
56
231
(100%)
Table 4: Change in hand washing prevalence (2007 and 2008)
Hand washing
frequency
2007
Yes
No
Not
always
Total
Hand washing frequency 2008
Not
No
always
Total
Yes
Count
Count
Count (%)
Count (%)
(%)
(%)
205 (68.8%) 6 (2%)
8(2.7%) 219 (73.5%)
0
14 (4.7%)
3 (1%)
11 (5.7%)
(0.0%)
53 (17.8%)
3 (1%)
6 (2%)
62 (20.8%)
272 (91.3%)
9 (3%)
17
(5.7%)
298
(100.0%)
On the above observed changes in hand washing in 2007 and 2008, the overall change
was slightly significant (χ²=9.34, P=0.053).
The results of hand-washing practice by age showed that there were changes across agegroups. The most significant change was observed in age group 36-45 years, whereby
the proportions increased from 66.7% to 88.9% (χ2 =10.014, P=0.04). Some
improvements were noted in other age groups but were not statistically significant. In
age group 14-25 years, the proportion of those who wash hands regularly increased
from 83.5% before intervention to 94.9% after intervention (χ2 =0.515, P=0.773). Handwashing practice also improved in age group 26-35 years, with those who wash hands
regularly increasing from 76.9% in 2007 to 93.5% in 2008 (χ2 =1.369, P=0.849). In age
group above 46 years, the proportion increased from 58.3% to 83.3%. The detailed
distribution is as shown in Table 5: -
57
Table 5: Change in hand washing in 2007 and 2008, grouped by age group
Washing of hands by age
group
14-25yrs
Yes
(n=79)
No
Not always
26-35yrs
Yes
(n=108)
No
Not always
36-45yrs
Yes
(n=63)
No
Not always
Over 46yrs
Yes
(n=48)
No
Not always
4.3.3
2007
Count (% of
Total) n=298
66 (83.5%)
2 (2.5%)
11 (13.9%)
83 (76.9%)
7 (6.5%)
18 (16.7%)
42 (66.7%)
5 (7.9%
16 (25.4%)
28 (58.3%)
3 (6.3%)
17 (35.4%)
2008
Count (% of
Total) n=298
75 (94.9%)
0 (0%)
4 (5.1%)
101 (93.5%)
3 (2.8%)
4 (3.7%)
56 (88.9%)
2 (3.2%)
5 (7.9%)
40 (83.3%)
4 (8.3%)
4 (8.3%)
χ2
0.515
Pvalue
0.773
1.369
0.849
10.014 0.04
4.105
0.392
Change in presence of hand washing practice
Presence of hand washing soap in the house was used as a proxy indicator to handwashing
practices. It was observed that within respondents with no education, soap presence increased
from about 65% to 78%, those with primary education increased from about 58% to 69% while
hand washing soap presence in households among those with post-primary education increased
from about 68% to 81%. This is as shown in Table 6: Table 6: Presence of soap in the house in 2007 and 2008, grouped by education level
Presence hand washing
soap
No education
Primary
Post-primary
Yes
No
Yes
No
Yes
No
2007
Count (% of
Total)
68 (65.4%)
36 (34.6%)
74 (57.8%)
54 (42.2%)
44 (67.7%)
21 (32.3%)
58
2008
Count (% of
Total)
81 (77.9%)
23 (22.1%)
89 (69.5%)
39 (30.5%)
53 (81.5%)
12 (18.5%)
χ2
P-value
3.871
0.049
0.031
0.860
0.359
0.549
The changes on presence of soap in house in 2007 and 2008 observed above shows that
those with no education was significant (χ²=3.87, P=0.049) hence not likely to have
been by chance whereas that of those with primary or post primary education might be
attributed to chance error (P>0.05).
4.3.4
Change in storage of drinking water practices
Regarding storage of drinking water practices, in Kakuma Division, those who kept drinking
water from closed containers increased from 35.5% to 80.5%. In Lodwar Central, they
increased from 37.7% to 77.5% while in Lokichogio, they increased from 39.5% to 80.3%. The
detailed distribution is as shown in Table 8: -
Table 7: Drinking water storage in 2007 and 2008, grouped by Division
2007
Count (% of
Storage of water for drinking
Total)
open container 49 (64.5%)
Kakuma
closed
27 (35.5%)
container
Lodwar Central open container 86 (62.3%)
closed
52 (37.7%)
container
open container 46 (60.5%)
Lokichogio
closed
30 (39.5%)
container
2008
Count (% of
Total)
15 (19.7%)
61 (80.3%)
χ2
P-value
1.967 0.161
31 (22.5%)
107 (77.5%)
0.953 0.329
15 (19.7%)
61 (80.3%)
1.503 0.220
The changes noted above in drinking water storage were not statistically significant
(P>0.05), hence may be attributable to chance error.
59
4.3.5
Change in handling and disposal of children faeces
The study also assessed methods of disposal of children faeces by observations and
interviews. At baseline, 61.8% (173) of the respondents disposed their children faeces
in the open by crudely throwing it in the compound or in the nearby bush. After the
intervention, open disposal of children faeces by the mothers decreased significantly to
43.2% (121). Very few mothers buried or covered the faeces with soil at baseline
(38.2%), however the practice changed significantly after intervention with 56.8% of
the mothers covering the faeces of their children with soil. This is as detailed in Table 9:
-
Table 8: Way of disposing off children faeces
Way of disposing off Leave it in the yard
faeces (2007)
and do nothing
Bury it
Total
Way of disposing off faeces
(2008)
Leave it in the
yard and do
nothing
Bury it
25% (70) 36.8% (103)
Total
61.8% (173)
18.2% (51)
20% (56)
43.2% (121) 56.8% (159)
38.2% (107)
100% (280)
The study also assessed faecal contamination within the compound mainly through spot
observations. There was some non-statistically significance improvement against
indiscriminate disposal of faeces in the compound after the intervention. Prior to the
intervention, it was observed that 131 (43.7%) of the compounds were littered with
faeces compared to 95 (31.7%) after intervention. This is as detailed in Figure 10: 60
Figure 10: Contamination of compound with faecal matter
4.4
Change in Health Outcome as Measured by Surrogate Parameters
The results in this section detail the observed changes in the quality of drinking water at
the point of use as measured by chlorine level, faecal coliform counts, changes in faecal
oral transmitted diseases, changes in microbes in stool of children aged below five
years.
4.4.1
Chlorine level and Faecal Coliform Count before and after intervention
As an indicator and measure to reduced risk of ill health, residual chlorine test was
carried out in households that claimed to be treating their water or consuming treated
water. Chlorine level of less than 0.2 mg/l as cut off was regarded low and in-effective
against harmful microbes; levels of chlorine of more than 0.2 mg/l in water were
regarded effective in protection against bacterial contamination. Overall, there was
marginal change in proportion of households whose drinking water had residual
chlorine of more than 0.2 mg/l; in Kakuma, the proportion of households whose
drinking water had residual chlorine of more than 0.2 mg/l increased from 12.9% in
61
2007 to 22.6 in 2008. Similar marginal changes were noted for Lodwar Central and
Lokichogio Divisions as shown in Table 10: -
Table 9: Chlorine Level in 2007 and in 2008
Chlorine Level
Kakuma
>0.2 mg/l
<0.2 mg/l
Lodwar Central >0.2 mg/l
<0.2 mg/l
Lokichogio
>0.2 mg/l
<0.2 mg/l
2007
Count (% of
Total)
8(12.9%)
54 (87.1%)
10(15.6%)
54 (84.4%)
10(16.1%)
52 (83.9%)
2008
Count (% of
Total)
14(22.6%)
48 (77.4%)
9(14.1%)
55 (85.9%)
11(17.7%)
51 (82.3%)
χ2
P-value
2.679 0.102
0.162 0.687
0.042 0.838
The proportion of households which had water with chlorine levels above 0.2 mg/l
marginally increased though the changes recorded were not statistically significant.
These observations are consistent with field expectations since there were no direct
interventions targeting increased chlorine use. This was by design so as to avoid
possible confounding effects on faecal coliform count arising from the known effects of
chlorine in reducing diarrhoea related diseases as compared to changing mothers’
behaviour.
Regarding observed changes in faecal coliform counts per 100 ml sample, there were
significant variations between 2007 and 2008. The reduction in mean faecal coliform
counts was notable in all divisions; in Kakuma, mean faecal coliforms per 100 ml
sample reduced from 72.6 to 26.2 colony units, similar results were recorded in Lodwar
62
Central where the number reduced from 83.7 to 22.6 units, while in Lokichogio
Division, the number reduced from 51.6 to 22.6 units. This is as shown the Table 11: -
Table 10: Paired Samples Statistics on faecal coliforms per 100 ml sample, grouped by
Division
Division
faecal coliforms in 100
Kakuma
mls in baseline
faecal coliforms in 100
mls in post intervention
Lodwar Central faecal coliforms in 100
mls in baseline
faecal coliforms in 100
mls in post intervention
faecal coliforms in 100
Lokichogio
mls in baseline
faecal coliforms in 100
mls in post intervention
95% CI
Sig.
Std.
N Mean Deviation Lower Upper (2-tailed)
62 72.58
102.9 46.44 98.72 0.005
49
26.18
24.9
61
83.75
113.1
79
22.59
21.5
17.79
27.40
60
51.62
68.4
33.94
69.29 0.006
39
22.59
16.7
17.16
28.02
19.02
33.35
54.78 112.73 0.003
The table above shows that there were significant differences in proportion of sample
with faecal coliform count at baseline (2007) and after intervention (2008).
63
4.4.2
Diarrhoea prevalence in children aged less than 5 years (before and after
intervention)
The overall prevalence of diarrhea among children a month before the study reduced
from 43.7% in 2007 to 30.7% in 2008. This is shown in Figure 11 below: Figure 11: Diarrhoea in children in the last one month prior and after the intervention
(2007-2008)
There was consistent reduction in diarrhoea among children as reported by mothers and
by level of education of mothers. Children of mothers with no education reported about
10% reduction in diarrhea (42.9% in 2007 to 35 (33.3%) in 2008, those of mothers with
primary education reducing from 48 (37.2%) in 2007 to 41 (31.8%) in 2008, while
those of mothers with post-primary education reducing from 38 (57.6%) in 2007 to 16
(24.2%) in 2008. This is detailed in the Table 12: -
64
Table 11: Cross-tabulation on child diarrhoea 1 month prior to study baseline (2007) and
diarrhoea 1 month prior to study end-line (2008) by Education level of the respondent
Did child have diarrhea 1
month prior to study
No education
No
Yes
Primary
No
Yes
Post-primary
No
Yes
2007
Count (% of
Total)
60 (57.1%
45 (42.9%
81 (62.8%
48 (37.2%
28 (42.4%
38 (57.6%
2008
Count (% of
Total)
70 (66.7%)
35 (33.3%)
88 (68.2%)
41 (31.8%)
50 (75.8%)
16 (24.2%)
χ2
P-value
0
1
0.01
0.920
4.846
0.028
As depicted in Table 15 above, the noted reduction in prevalence of diarrhoea increased
with education. The observed changes where only statistically significant for the
children of mothers with post-primary education (χ²=4.85, P=0.028).
65
4.4.3
Diarrhoea related microbes in children stool before and after intervention
A total of 230 stool specimens from children aged less than five years were examined at
baseline and one year thereafter (end-line). From the 230 stool samples examined, the
proportion of children from whom infectious pathogens of Proteus spp. was isolated,
reduced from 30 (16%) to 16 (7%), E. coli reduced from 125 (54%) to 95 (41%) while
salmonella spp. increased from 6 (1%) to 19 (8%). Specimen outside from children
aged more than five years where excluded, they increased from 18 (8%) to 62 (27%).
The detailed distribution of the microbes is as shown in Figure 12: -
60%
2007
Proportion (%)
50%
2008
40%
30%
20%
10%
itr
o
ba
ct
er
te
r
C
te
ro
b
ac
sp
En
Sh
ig
e
lla
la
el
Sa
lm
on
p.
sp
p.
li
Eco
el
la
si
Kl
eb
sp
p.
s
Pr
ot
eu
N
o
gr
ow
th
0%
Microbes in children stool
Figure 12: Distribution of Microbes in Stool specimens from Children Aged Less Than 5
Years at baseline and End line
66
Overall, prevalence of diarrhoea related microbes in children aged less than five years
reduced from 91.3% in 2007 to 78.3% after intervention (2008); this is as depicted in
Figure 13: -
Figure 13: Diarrhoea related microbes in children stool at baseline and endline (20072008)
However, it is clear from the statistics that there was no significant change in diarrhoea
related microbes in children stool before and after intervention (χ2 =47.32, P=0.5).
4.4.4
Prevalence of Bacterial and Parasitic organisms in children aged less than 5
years
The prevalence of bacterial and parasitic organisms from the stool of children aged less
than five years was assessed through laboratory examination of stool samples in the
laboratory. The results of the findings were as shown Table 13;
67
Table 12: Ova and Cyst and Bacterial and parasitic pathogens in stool
Ova and Cyst in stool
A Lumbricoides
E histolytica trophozoite
Giardia lamblia Trophozoite
T. trichuris
No Cyst/Ova
Salmonella
Shigella
Total
2007
2008
Frequency
(%)
10(3.5)
23(8.1)
10(3.5)
1(0.4)
224(78.6)
15(5.3)
2(0.7)
285 (100)
Frequency (%)
Chisquare
6(2.1)
12(4.1)
1(0.4)
0
262(90.03)
3(1.0)
7(2.4)
291 (100)
Pvalue
0.1
0.25
0.35
0.74
0.62
0.85
4.1
8
2.78
0.04
0.005
0.096
From the 285 and 291 stool samples examined at baseline and after intervention
respectively, potential infectious pathogen was isolated from 61 (21%) of the children at
baseline and 29 (10%) of the children after intervention. Bacterial pathogens were
isolated from 17 (6.0%) of the children at the baseline study and 10 (3.4%) of the
children after intervention. Parasitic pathogens were isolated from 34 (15.5%) of the
children at baseline and 19 (6.6%) of the children after intervention.
4.5
Linkages between mother’s
improvement indicators
behaviour
and
targeted
health
4.5.1
Relationship between mother’s behavioural factors and Faecal coliform
Count
After establishing the significant variables related to health promotion role in improving
mothers and children health, it was necessary to explore the statistical strengths of such
variables in influencing the said outcome. This sub-section applies multivariate analysis
68
to explain the nature of such independent variables and quantifies their strengths in
influencing the expected health outcome (dependent variable). To achieve this,
regression models were applied.
As shown in Figure 14, 65.7% of the population did not have faecal coliform in their
drinking water samples.
Figure 14: Change in faecal coliform count between 2007 and 2008
For comparative change (2007 and 2008), 20.1% of the households had faecal coliform
reduction while 14.3% had FC increase and the rest had no report for various reasons
including many children not able to produce stool. Out of the 91 respondents who
69
reported change in faecal coliform count per 100 ml of drinking water, majority
(10.7%) had FC reductions of more than 50 units as compared to 10% with FC increase
of 1 to 25 units per 100 ml drinking water sample. For 91 respondents who reported
change in faecal coliform count per 100 ml of drinking water, the nature and strength of
association with previously noted modifiable behavioural variables was explored
through linear regression modelling. Notably, the resulting model had an R-square of
39.6% (P=0.048). This means that about 40% of the observed change in faecal coliform
count per 100 ml of drinking water could be explained or attributed to the observed
change in mothers behaviour. The specific modifiable risk factors under mothers
behaviour are as summarized in Table 14: Table 13: Resulting model Coefficients on association between FC change and modifiable
behavioural risk factors
Unstandardized Standardized
95% Confidence
Dependent
Variable:
Coefficients
Coefficients
Interval for B
Faecal Coliform count
Std.
Lower Upper
per 100ml (change)
B
Error
Beta
t Sig. Bound Bound
(Constant)
1.724 1.043
1.653 .112 -.439
3.887
Age of the respondent
0.612 .233
0.412
2.624 .015 0.128
1.096
Reasons for no toilet 0.749 .241
0.508
3.107 .005 0.249
1.248
facility (2007)
Do you have a toilet -1.662 .751
-.365
.038 -3.220 -.103
facility (2007)
2.211
Resulting model: Y=1.7 + 0.41X1 +0.0.51X2 - 0.36X3
Where; Y=FC count/100ml (change),
X1= age of Respondent, X2= reason for no toilet in 2007, X3=Presence of toilet facility
in 2007
70
Indicatively, the faecal coliform count can be determined (predicted) using key risk
factors which are namely; age of Respondent (P=0.015), reason for no toilet in 2007
(P=0.005), and presence of toilet facility in 2007 (P=0.038). The resulting model was
highly suitable as shown by the test of residuals represented by the histogram and
normal probability plots shown in Figure 15: -
Figure 15: Normal probability plots of residuals
71
The model as depicted above indicates that the observed residual probabilities are
highly correlated to those resulting from the model hence an indication of model goodfit to the observed data as shown in Figure 16: -
Figure 16: Histogram on dispersion of residuals
As an indicator of model appropriateness, the residuals (un accounted variability by the
model) are randomly distributed hence fit in a normal distribution curve as shown
above.
72
4.5.2
Relationship between mother’s behavioural and related factors and
diarrhoea microbes in children stool
From a multi-variate regression using forward stepwise removal (likelihood ratio), the
association between the noted reduction of diarrhoea related microbes in children stool
of 91.3% in 2007 to 78.3% after intervention (2008) is based on the modifiable risk
factors outlined in Table 15: -
Table 14: Association between microbes in children stool, mother’s behaviour and related
factors
Variables in the Equation
95% C.I. for EXP(B)
B
S.E.
Sig. Exp(B) Lower
Upper
Age
-0.54 0.45
0.227 0.58
0.24
1.40
Education
1.95
0.91
1.17
41.92
0.033 7.02
Toilet’08
-4.29 1.88
0.00
0.54
0.022 0.01
Distance’08
3.39
1.17
295.60
0.004 29.71 2.99
Water sources;
0.019
Sources(Open
7.28
2.34
144253.71
0.002 1456.0 14.70
well)
6
Sources(spring)
-.12
1.27
0.01 1 0.928 0.89
0.07
10.66
Sources(river)
2.82
1.34
4.40 1 0.036 16.71 1.20
232.32
Treatment’08
3.31
1.34
6.13 1 0.013 27.40 1.99
376.87
Storage’08
-2.44 1.33
3.35 1 0.067 0.09
0.01
1.19
Constant
-32.98 8182.10 0.00 1 0.997 0.00
Resulting model: Y= -32.98 -0.54X1+1.95X2 –4.29X3 +3.39X4 +(coeff. of applicable water
source)
Wal
d
1.46
4.56
5.22
8.37
9.91
9.65
d
f
1
1
1
1
3
1
Where; Y= Microbe in stool in 2008 (Reclassified),
X1= age of Respondent, X2= education level of respondent, X3=Presence of toilet facility
in 2008, X4=distance from toilet facility in 2008
The driving factors to diarrhoea related microbes in children stool could thus be linked
strongly to mothers behavioural characteristics; namely mother’s education, toilet
73
availability, distance to toilet, source of drinking water, treatment of drinking water and
storage of the drinking water. The strength of the model as judged by its ability to
classify correctly whether the respondent’s child stool has diarrhoeal related microbe or
not is judged from its overall positive predictive value (PPV) which in this case was
92.7% as shown in Table 16: Table 15: Classification table on the association between microbes in children stool and
mothers behaviour
Predicted
Microbe in
(Reclassified)
stool
in
2008
Diarrhoeal
No growth/Not Percentage
related microbes applicable
Correct
Observed
Microbe in stool in Diarrhoeal related microbes 65
2008
No growth/Not applicable
4
(Reclassified)
Overall Percentage
2
97.0
11
73.3
92.7
The above table shows that the microbes in stool prediction model was able to correctly
predict 97% of the samples with diarrhoeal related microbes (sensitivity) and 73.3% of
samples without diarrhoeal related microbes (specificity) with an overall PPV of 92.7%.
74
4.5.3
Association between modifiable behavioural and related factors and
diarrhoea prevalence in children aged less than 5 yrs
From binary logistic regression using forward stepwise removal (likelihood ratio),the
association between the noted diarrhoea prevalence reduction from 43.7% (in 2007) to
30.7% after intervention (2008) in children aged less than five years is based on the
modifiable risk factors outlined in Table 17: Table 16: Association between modifiable behavioural and related factors and diarrhoea
in children aged less than 5 Years
Variables
in
the
equation/predictors
Diarrh2007
education
structure
Latrine08
clorine08
Constant
B
2.247
-1.770
3.959
3.322
-6.759
-5.147
S.E.
1.029
.698
1.267
1.587
3.507
2.602
Wald
4.770
6.429
9.765
4.381
3.713
3.914
df
1
1
1
1
1
1
Sig.
0.029
0.011
0.002
0.036
0.054
0.048
Exp(B)
9.459
.170
52.416
27.719
.001
.006
95%
EXP(B)
Lower
1.259
.043
4.375
1.235
.000
C.I.for
Upper
71.049
.669
627.952
621.926
1.123
Resulting model: Y= -5.15 + 2.25X1 -1.77X2 + 3.96X3 + 3.32X4 -6.76X5
Where; Y=FC count/100ml (change),
X1= Diarrhrea prevalence in 2007, X2= education level of respondent, X3=latrine structure
X4=Latrine presence in 2008, X5=latrine Chlorine level in 2008
The risk factors for diarrhea in children aged less than five years after intervention
(2008) are mainly behavioural characteristics; namely if the child had diarrhoea at
baseline (2007), mother’s education, latrine availability, latrine structure and chlorine
level in the drinking water after the intervention (2008).
75
The strength of the associative model as judged by its ability to classify correctly
whether children aged less than five years suffered from diarrhoea episode or not is
judged from its overall positive predictive value (PPV) which in this case was 77.8% as
shown in Table 18: Table 17: Classification table on the association between sanitation and hygiene promotion
and diarrhoea in children aged less than 5 Years
Predicted
Observed
Did child have diarrhoea 1
month prior to study (2008)
Percentage
No
Yes
Correct
Step 5 Did child have diarrhoea 1 No 17
6
73.9
month prior to study (2008)
Yes 4
18
81.8
Overall Percentage
77.8
a. The cut value is 0.5
The table above shows that the diarrhoea predictive model was able to predict73.9% of
the non-diarrhoeal (specificity) related samples correctly and 81.8% of the diarrhoea
samples (sensitivity) correctly with an overall PPV of 77.8%.
76
CHAPTER FIVE
5.0
DISCUSSION, CONCLUSION AND RECOMMENDATIONS
5.1
Discussion
The function of hygienic behaviour is to prevent the transmission of the agents of infection.
In a previous study, effects of improved environmental sanitation conditions and hygiene
practices on preventing occurrence of diarrhoea among children under five years included
washing and purifying fruits and vegetables; domestic water reservoir conditions; faeces
disposal, presence of vectors in the house and flooding in the lot (Heller et al., 2003).
This study compares with that of Heller et al., 2003. The study intervention was to change
mothers sanitation and hygiene behaviour and practices to impact on improving children
health in Turkana District. The targeted behaviour and practices included: House hold
water treatment and safe storage, Hand washing with soap, Provision and use of latrine and
safe disposal of children faecal matter. These interventions were targeting mothers of
children under five years of age whose outcome was envisioned to be reduction of
diarrhoeal among children under five years in the study area. Two approaches were used to
deliver the interventions; Community led total sanitation (CLTS) and Participatory hygiene
and sanitation transformation (PHAST).
77
This part of the report delve into the possible reasons in support of key findings on
mother’s behaviour and influence on the health of children aged less than five years in
Turkana District and possibly other areas of similar socio-economic constraints. This was
by comparing the findings with previous studies undertaken elsewhere.
5.1.1 Changing community sanitation and hygiene knowledge and practices
Inadequate sanitation is a major cause of infectious diseases globally and improving
sanitation is known to have a significant beneficial impact on health both at household
level and across communities. Provision of latrines as a measure to prevent communicable
disease cannot thus be over emphasized and one of the interventions for this study was
provision of basic latrines under the community total led sanitation (CLTS). The
communities’ knowledge on importance of latrines in this regard seems not to have
increased significantly as expected with a significant number giving privacy as the priority
reason for use of latrine 33.7% of the respondents compared to 62.3% who associated
latrines with disease prevention.
Socio-cultural and contextual factors such as, low socioeconomic status, low education
levels, social instability and gender disparities can lead communities to compromise in
hygiene and sanitation issues. Turkana District has acute water shortage and many
communities in the District experience the negative effects associated with this inadequacy.
This scenario has greatly led to the deterioration of sanitation and hygiene services leading
to poor health and physical devastation. As Van Wijk-Sijbesma (1998) asserts,
participation of women in health interventions in water scarce areas can bring distinct
78
benefits to water sanitation and hygiene as a whole. Therefore, in an effort to improve
health status in a more sustainable way in this study a number of interventions were
designed and evaluated targeting women.
In this study, majority of the respondents were middle aged mothers of between 26 to 35
years (36.3%) and the highest proportion of them had primary school level education
(43%). For this study, various gains were recorded between the baseline (2007) and postintervention (2008). Amongst the gains were that baseline findings established that
majority of the respondents disposed their children’s waste in the open, but that changed
significantly after the intervention. Specifically, latrine coverage by type changed
significantly, with the number of traditional pit latrine household ownership increasing
from 45.5% to 63.6% as opposed to ventilated improved pit latrine household ownership
that fell from 54.5% to 36.4% (χ²=4.43, P=0.035).
In a similar study undertaken to determine whether a large 3-year hygiene promotion
programme in Bobo-Dioulasso, Burkina Faso was effective in changing behaviours
associated with the spread of diarrhoeal diseases, some notable gains included safe disposal
of children’s stools, that increased from 80% at pre-intervention (1995) to 84% post (1998).
There was reduced prevalence of diarrhoea and improved general health status of children
aged less than five years.
79
The observed health gains are associated with differences in community involvement and
the participatory approach adopted. The Turkana study interventional approach involved
Participatory Hygiene and Sanitation Transformation (PHAST) that integrated the
principles of Community Led Total Sanitation (CLTS). CLTS basically trigger
communities into demanding hygiene and sanitation facilities. The key challenge in
implementation of effective sanitation and hygiene is the up-scaling in the local
communities and domesticating the tools to suit the local conditions. As reported by Kamal
Kar (2003), in India, use of PHAST is highly effective when integrated with CLTS
programs that seek to create a sense of disgust and shame against open excreta disposal.
However, there are many challenges in implementation of effective sanitation and hygiene
interventions especially up-scaling it in local communities and domesticating the tools to
suit local conditions in resource poor areas. This study had similar challenges in that there
were varying socio-economic strata of the beneficiary community. Specifically, there are
several socioeconomic and cultural cross cutting factors which affect the availability and
the type of the toilets within the households. Lack of money to purchase the hardware was
the main reason for not having a toilet. Responsive approaches allow communities in
different socio-economic groups to express their social, economic and environmental
demands; though incentives to sanitation, hygiene, value and honour should be viewed in
commensurate to the community’s development status.
80
In the developing world today, diarrheal diseases are amongst the leading causes of child
mortality and it has been shown that the simple act of washing hands with soap can
decrease diarrhea risk by almost half. A study on hand washing practice conducted in
Korea noted that out of the 942 students who participated there was a 30.3% increase in
hand washing an improvement of one carried out one year earlier. (Jae-Hyun Park et al.,
2010). In Turkana, targeted interventions recorded significant gains in the habit of hand
washing practice. In Lodwar Central, those who wash hands regularly increased from
85.5% to 89.9% (χ²=10.85, P=0.028). In Lokichogio Division, the proportions increased
from 77.5% to 93.8% (χ²=15.56, P=0.004) whereas in Kakuma Division, hand washing
practice increased from 48.8% to 91.3% (χ²=7.28, P=0.122). These results show that
targeted interventions aimed at increasing hand washing practice should be encouraged
across all communities irrespective of their socio-economic strata.
In addition, presence of soap in households changed between 2007 and 2008 with that of
those with no education increasing from 65.4% to 77.9% (χ²=3.87, P=0.049). These
finding are comparable to those of the Bobo-Dioulasso, Burkina Faso study that noted
presence of soap increased hand-washing with soap during critical times such as after
cleaning a child’s bottom, which rose from 13% to 31% (Sidibe and Curtis, 2002).
Similarly, the proportion of mothers who washed their hands with soap after using the
latrine increased from 1% to 17%. However, it is also notable that both the Burkina Faso
study and Turkana study checked on hand-washing during critical times including before
eating any meal.
81
The promotion of hygienic behaviour especially hand washing has been identified as a
public health intervention likely to have considerable impact in the reduction of diarrhoeal
diseases in young children in developing Countries (McLennan, 2000). While washing
hands at critical times is accepted as an effective intervention against diarrhoeal disease,
evidence is also now growing for its effectiveness against respiratory infections
(Cairncross, 2003). Based on the results of the Turkana study, up-scaling of hand washing
with soap practice is highly recommended, especially using the germ theory to promote
healthy behaviour.
This study reveals that hand washing practice increased exponentially with age. Significant
improvements was observed in the age group between 36 and 45 years of age with increase
from 66.7% in 2007 to 88.9% in 2008 ((χ²=10.01, P=0.04). This observation had protective
effect especially among the child bearing group for their own hygiene and that of their
small children.
These results compares well with other studies by the World Bank, Water and Sanitation
programme in Cambodia which have shown that health improvement can be easily
registered in resource constraint communities by applying different approaches and
solutions (WSP, 2002). Although the results of the post intervention measures showed that
there was increase in hand washing, sustainability of the activities is unpredictable in the
event of prolonged drought leading to inadequate water.
82
5.1.2
Changing community health outcome measures
The effectiveness of interventions like the ones noted above is usually measured by
changes in behaviours, on the assumption that change in behaviour will usually be reflected
in reduced morbidity and mortality (Curtis, 2003). The question of whether health
education and hygiene promotion actually leads to reduction in disease burden in the
community has always elicited mixed results. A paper on the experience of Bawku West
District in Ghana noted that despite many efforts by both government and nongovernmental organizations in providing water and sanitation infrastructure, health
education and hygiene promotion, little had been achieved in reduction of water and
sanitation related diseases or improvement in hygiene behaviours.
Mixed results noted in the approach above is first to establish whether there was any
significant change in community related behavioural variables as well as health outcomes
after the intervention. Contrary to the above observations, the Turkana study demonstrated
significant changes in behaviour related variables including decrease in faecal coliform
count in drinking water, and diarrhoea related microbes in children stool as biological
proxy indicators of community health outcomes. Chlorine levels measured to control for
possible confounding effects did not have significant differences before and after
intervention. The differences between the Turkana study and that of Ghana may have
arisen from the approaches employed. It may also be attributed to varying pre-existing
levels of hygiene in the two districts besides differences in cultural and socio-economic
83
status. Community behaviour change is a function of many and complex variable
combination and it is also possible that the two areas were totally different in many aspects.
In the study, the mean chlorine level was found to be the same in 2007 and 2008 (no
significant difference) whereas mean faecal coliforms per 100ml drinking water sample
varied significantly between 2007 and 2008. In Kakuma, mean faecal coliform count
reduced significantly from 88 to 30.2 units (P=0.005), while in Lodwar Central, the
coliform count reduced significantly from 91 to 17.3 units (P=0.003), and in Lokichogio
Division, the coliform count reduced significantly from 63.8 to 23.6 units (P=0.006). For
diarrhoeal related microbes in children stool, this study established that there was a
reduction from 91.3% in 2007 to 78.3% after intervention. However, this study did not find
any previous related publications measuring drinking water faecal coliform count nor
diarrhoea related microbes in children stool before and after intervention in the same
population hence difficulties in providing direct comparative findings.
84
5.1.3 Effectiveness of hygiene and sanitation interventions in changing mother’s
hygiene behaviour and improving child health
Although hygiene promotion is a tenet of many health programmes, doubts remain about
its effectiveness. A previous review of over 500 articles on health education in developing
countries that were published in 1987 found only three with satisfactory evidence of
behaviour change or an impact on health.
According to this study, the reduction noted above in coliform count resulted from
improvements in mother’s behaviour and was strongly associated with an R-square of
39.6%. The three key influencing variables included; age of the mother (P=0.015),
presence of latrine (P=0.038), and reasons given at baseline for not having latrine
(P=0.005). This means that the three identified variables explain about 40% of the
observed relationships between coliform count and mother’s behaviour. This shows that
any hygiene and sanitation promotion intervention should target women of mid-age
parenthood between 26 to 35 years and should include all possible means to increase latrine
ownership as well as change community perception on latrine ownership amongst other
interventions since these factors contributes about 40% of faecal contamination of drinking
water.
On the other hand, this study also established with high certainty (positive predictive value
of 92.7%, P<0.0001) that certain mother’s behavioural risk factors are key predictors of
presence or absence of diarrhoea related microbes in children aged less than five years.
85
They are namely; mothers education level (P=0.033), toilet presence (P=0.022), distance to
latrine (P=0.004), source of drinking water (P=0.019), treatment of drinking water
(P=0.013) and drinking water storage (P=0.067). As previously noted, there are no
comparative studies to date.
Ultimately, diarrhoea prevalence in children aged less than five years was found to be
highly linked to mother’s behavioural characteristics; namely,
1.
If the child had diarrhoea at baseline (2007), it was highly likely that the same child
would have diarrhoea at end line (after one year of intervention);
2.
Mother’s education, a factor that was not expected to change over the period of
intervention;
3.
Latrine availability and latrine structure which were core areas of intervention,
hence shows that there was marked differences between those who had a latrine
facility as compared to those who did not have the facility;
4.
Chlorine level, indicating that though the chlorine levels did not change
significantly between baseline and end line, there was protective effect against child
diarrhoea for those who used chlorinated water.
The above four variables are hence core modifiable factors in any hygiene and sanitation
promotion project.
86
5.2
Conclusions
This study found that most mothers in Turkana District were within 26 and 35 years age
bracket and belonged to low socio-economic and education levels. This is a common
phenomenon in many other communities and therefore the study results are likely to
apply beyond Turkana District.
Sanitation and hygiene promotion based on the approach of PHAST was highly
effective in changing sanitation and hygiene behaviour and practices of mothers when
integrated to Community Led Total Sanitation (CLTS) programs that seek to create a
sense of disgust and shame against open excreta disposal. The specific gains included
increased latrine coverage by type, that changed significantly with the number of
traditional pit latrine household ownership increasing by 18.1%, change in hand
washing practice achieved a high of 42.5% in Kakuma Division with an overall 22%
increase within the age group 36 to 45 years, presence of soap in households increased
by 12.5% within the group who had no education.
There was overall significant improvement in community health outcomes before and
after the intervention with comparative reduction in faecal coliform count in drinking
water ranging from 40.2% to 73.7%. Similarly, diarrhoea related microbes in children
stool reduced by 13%.
Hygiene and sanitation interventions were found to improve in changing mother’s
hygiene behaviour and improving child health by reducing faecal coliform count by
87
about 40% with age of the mother, presence of latrine and reasons given at baseline for
not having latrine being the key determinants. On the other hand, diarrhoea related
microbes presence or absence could be predicted with an overall 92.7% (97% for the
diarrhoeal related samples and 73% for those with no microbes correctly identified by
modeling) precision using core determinants/predictors as mothers education level,
toilet presence, distance to latrine (P=0.004), source of drinking water, treatment of
drinking water and drinking water storage container.
The results of the study confirms the first hypothesis that Sanitation and hygiene
interventions have no effect in changing mother’s knowledge in sanitation and hygiene
before and after the intervention (p=0. 476). The second hypothesis has been rejected
after the results showed significant changes in handing washing practice Lokichogio
p=0.004 and Central Lodwar p= 0.028. The third hypothesis has also been rejected as
Sanitation and hygiene interventions was seen to have effect in changing faecal coliform
count in drinking water at the point of use before and after the intervention with a p value of <
0.0005. The fifth and sixth hypothesis were also rejected based on the fact that their was
reduction in diarrhoeal among children less than five years before and after the intervention
Ultimately, it was strongly established that any hygiene and sanitation promotion
project should consider diarrhoea at baseline, mother’s education, latrine availability
and structure and use of chlorine as the core predictors and modifiable factors against
childhood diarrhoea.
88
5.3
Recommendations
1.
Skills training and enhancement at the household level within the
community – The study found that the community comprises of individuals of
low socio-economic status and it would be appropriate to enhance their skills in
human excreta disposal and household water treatment. Post intervention
measures showed general improvement on excreta management and this should
be scaled up or replicated in other communities.
1
Interventions aimed at improving sanitation and hygiene in communities
should always include targeted behaviour change interventions -Adopt and
upscale community based participatory approaches as used in this study to
overcome sanitation and hygiene barriers in resource constrained communities by
application of relevant participatory approaches such as CLTS and PHAST.
2
Multiple targeted interventions focused to resolve the barriers to sanitation
and hygiene should be implemented - Based on whatever barriers defined by
different communities, multiple high impact interventions applied in this study
including hand washing with soap, household water treatment and safe storage and
improved human waste disposal facilities should be implemented complimentarily.
This ensures needs based approach to curbing sanitation and hygiene problems
within the communities.
3
Additional targeted research - Based on findings of this study and related
previous publications, it is important to undertake a focused research on the
89
economies of scale between application and effectiveness of ‘point of use’ water
treatment as compared to public interventions applied in this study, as well as their
combined benefits. There is also a need to carry out a more focused knowledge,
attitude and practice study which could not be well covered in this research.
90
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APPENDICES
APPENDIX 1: HOUSEHOLD QUESTIONNAIRE
A . GENERAL INFORMATION.
District: __________________________Division____________________________________
Location: ________________________
Sub
location:
____________________________
__
Village___________________________Household Head Name ________________________
Cluster No___________________________________________________________________
Date of interview (dd/mm/yyyy)__________________________________________________
Time of interview______________________________________________________________
Name of interviewer___________________________________________________________
Ask to speak to the head of the housed hold, if unavailable ask to speak to the mother of the
under Five or guardian or caretaker. Introduce your self and purpose of the study .
102
B.HOUSEHOLD BACKGROUND INFORMATION
1.Household head Sex (DO NOT ASK, CIRCLE CORRECT RESPONSE)
1 Male
2.Female
2.How old are you? ( TICK THE CORRECT RANGE FROM THE TABLE BELOW)
Age of Household Head Member
Age group
14 – 25
26 – 35
36 – 45
Over 46 yrs
Male
Female
REQUEST TO SPEAK TO THE MOTHER OF THE UNDER FIVE IF SHE IS NOT
THE HOUSEHOLD HEAD OR THE CARE TAKER/GUARDIAN
3 How old are you? (TICK THE CORRECT AGE RANGE FROM THE TABLE
BELOW)
Age of mother of the under five, Guardian or care taker
Age group
14 – 25
26 – 35
36 – 45
Over 46 yrs
Male
Female
4.Marital Status
Household head
Mother
Married
Single
Separated
Widowed
Divorced
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Guardian/Caretaker
N/A
5.How many people live in this household? (The definition of household is people eating from
the same kitchen/pot) _____________________________________
6.Their Sex and Ages in years of Household members
Age group
Under 5yrs
5 – 10
11 – 14
15 – 25
> 25 yrs
Male
Female
7.Highest level of education.
Complete the following after probing the responded on education status
Household
head
Mother
Under five
No education
Some Primary
Finished Primary
Some secondary
Finished secondary
Some tertiary
Completed Cert., Diploma, higher
Diploma etc
8.Occupation:
1. Business
3. Farming
5. Fishing
2. Salaried employment
4. Patrolism
6. Other (specify)________________
9.Tick type of house structures.
1 Permanent House
2 Grass thatched house
104
of Care
Taker/
Guardian
3 Semi-Permanent House
4 Manyatta
C. SANITATION
Now I am going to ask a few questions about sanitation and personal hygiene
10.Do you have a toilet facility in this compound?
If Yes > Go to No.14
If No- proceed to no.11
11.Why is there no toilet in this compound?
1.Can’t afford it
2.Soil too loose/Rocky
3.Do not need one
4.Collapsed and full
5.Other (specify)__________________
12.Where do you go to make a long call (defecate) if you don’t have a latrine at home?
1
2
3
4
5
6.
7.
On compound grounds somewhere
Behind the house
Friend’s house
Public latrine
Neighbour’s house
Bush/field
Others (specify)____________________________
13.Where do you make a short call (Urinate) if you not have a latrine at home?
1 On compound grounds somewhere
2 Behind the house
3 Friend’s house
4 Public latrine
5 Neighbour’s house
6 Bush/field
105
7
Other (specify)____________________________
14.How many latrines in this compound are currently functioning?
(If more than one facility is functioning in the compound address all functioning latrines)
15.Do you share this/these latrine(s) with other household(s)?
1.Yes
2.No
16.How many other households use this/these toilet(s)? ___________Households
17.Approximately how many individuals regularly use this/these toilets?____________
18.Is there any one in this household, including children, who does not regularly use the
latrine?
1.Yes
2.No
19.Who doesn’t regularly use the latrine?
1. Children<2 years
2.Children < 5years
3.Children 5-15 years
4.Female adults
5.Male adults
6.No one uses the latrine
7.Other (specify)_________
20.Why do these people not use the latrine?
(May have to change the answers based on who’s in---)
106
1.
2.
3.
4.
5.
6.
7.
Children too small
Not at home
Not well kept
Distance from the compound
Fear, dislike
Beliefs: customs/ taboos
Other (specify)_________________
21.How do you dispose off the faeces of your child/children under 5 years?
1. Leave it in the yard and do nothing
2. Put in the latrine
3. Bury it
4. Don’t know
5. Other (specify)_________________
23.How often do you clean your toilet?
1. Once a day
2. Once a week
3. Once a forty night
4. When it is dirty
5. Do not clean at all
24. a) Do you have a refuse pit?
1. Yes
2. No
b) If No, where do you dispose your refuse?
1. Open land
2 Toilet
3. Burning
D.OBSERVATIONS ON SANITATION
25.Is there evidence of faecal contamination within the compound?
1.Yes
2. No
107
26.a) Can you show me please the type of latrine that you are using?
No. of functioning latrines observed around the compound ____________
b) Type of toilet facility in compound. If more than one, determine the newest
Flush toilet)
1. Traditional Pit latrine
2. Ventilated Improved Pit Latrine
3. No facility/ bush/field
4. Other (specify)_________________________________
27.How far is the latrine from the dwelling house?
1. Less than 10 m
2. 10-20 m
3. More than 20 m
28.Conditions of latrine
a) Contains concrete slab.
1 Slab present. 2 Slab absent
b). Smell
1 No smell
2 smell inside 3 Smell outside latrine
c). Cleanliness
1 clean
2 slightly dirty 3 Presence of faeces
d). Flies
1 No flies
2 a few flies
3 many flies
e). Superstructure
1 No cracks
2 Crack s
3 Visible holes
f). Condition of slab
1 No cracks
2 Cracks
g). Door
1 door closes completely
3 Pit visible
2 Closes but not completely 3 No door.
8. Others (specify)___________________________________
30. a) Do you know importance of using a latrine?
1. Yes
2. No
b) If yes what are the importance?
1. Privacy
2. Status
3. Prevention of disease
4. Do not know
108
5. Other (specify)________________________________________________
31.a) Do you know diseases related to using latrine?
1. Yes
2. No
b). If yes, name them;
1.Typhoid
5.Malaria
2. Cholera
6.URTI
3. Hook worms
7. HIV/AIDs
4.Diarrhoea
8.other (specify)____________________________________
c) How can we prevent these diseases mentioned above ?
1.use of pit latrine
7.Cover food.
2.wash babies
8.Go to hospital
3.Treat water
9.Traditional healer
4.eat well
10.prayer
5.wash hands
11.other (specify)__________________
E.WATER SOURCES HANDLING, STORAGE AND TREATMENT
I am now going to ask you a few questions about your water source and handling
practices
32.What sources of water does your family use for cooking, washing, bathing or cleaning
throughout the year? (Do not include sources used only for agriculture or animals)
(Multiple responses possible)
Piped into dwelling
Piped into school
Public tap (outside school)
Open well in compound
Open public well
Covered well/borehole in compound
Covered public well/Borehole
Spring – Protected
Spring – unprotected
River Stream
109
11
12
13
21
22
31
32
33
41
42
Lake
Pond/Dam/Earth pan
Rainwater/Roof catchments
Water Vendor
Bottle water
No water available
Don’t know
43
44
51
61
71
98
99
33.What source of drinking water do you use most frequently during the rainy season?
(Choose one)
Piped into dwelling
Piped into school
Public tap (Outside school)
Open well in compound
Open public well
Covered well/Borehole in compound
Covered Public well/Borehole
Spring – protected
Spring – unprotected
River/Stream
Lake
Pond/dam/Earth pan
Rainwater/roof catchment
Water vendor
Bottled water
No Water Available
Don’t know
11
12
13
21
22
31
32
33
41
42
43
44
51
61
71
98
99
34.Approximately, how long does it take you to get the water from this source and
come back? (Do not read. If range, write the middle of range)
On premises
110
____ Minutes
____ Hours (convert to minutes)
35.How much water do members of your family collect/take from this source daily?
_____ Litres
36.Approximately how many litres of water does your family use for drinking daily during the
rainy season?
_____ Litres
37.Is the water you collect from this source sufficient for drinking needs of your family:
1.Always
2.Sometimes
3.Never
38.How frequently is water available from this source during the rainy season?
1.Always available
2.Several Hours per day
3.Once or twice per week
4.Infrequently
39.What did you use this water for?
1.Drinking only
2.Bathing/Hygiene/hand washing/
3.Washing clothes/cleaning compound
4.Animals/Agriculture
5.Cooking.
6.Other (specify)________________________________________________
40.Do you have to pay for this source?
_____Ksh per ______ Litres (convert to Ksh/Litre) (If answer “jerry can”, determine size)
111
41.What source of drinking water do you use most frequently during the dry season? (choose
one)
Piped into dwelling
Piped into school
Public tap (outside school)
Open well in compound
Open public well
Covered well/borehole in compound
Covered public well/Borehole
Spring – Protected
Spring – unprotected
River Stream
Lake
Pond/Dam/Earth pan
Rainwater/Roof catchment
Water Vendor
Bottle water
No water available
Don’t know
11
12
13
21
22
31
32
33
41
42
43
44
51
61
71
98
99
42.Approximately, how long does it take you to get the water from this source and come back?
1.On premises
2. _____________ Minutes
3. _____________ Hours (convert to minutes)
43.How much water do members of your family collect/take from this source daily?
_____________ Litres
44.Is the water you collect from this source sufficient for drinking needs of your family?
1.Always
2.Some time
3.Never
45.How frequently is water available from this source during the dry season?
1.Always available
2.Several Hours per day
3.Once or twice per week
112
4.Infrequently
46.What did you use this water for?
1.Drinking only
2.Bathing/Hygiene/hand washing/
3.Washing clothes/cleaning compound
4.Animals/Agriculture
5.Others (specify)___________________
47.Do you have to pay for this source?
1.Yes
2.No
48. How much do you have to pay?
_____KSH per ______ Litres (convert to KSH/Litre) (If answer “jerry can”, determine size)
49.Do you consider water from the current source safe for drinking?
1.Yes
1
2.No
2
3.Don’t Know
99
50.a) Do you treat your water to make it safe for drinking?
1.Yes
1
2.No
2
3.Don’t Know
99
b) If yes how do you treat your water?
1.Boiling water
2.Use of household filters
3.Use of waterguard
4.Treating water with PUR
5.Traditional herbs
6.Three pot system
7.SODIS
8.Chlorine based tablets
Others(specify)_________
F.HAND WASHING PRACTICES
51. a) Do you often wash your hands?
1.Yes
2.No
113
9.
3.Not Always.
b) When do you wash your hands? (Multiple responses possible)
1.Never
2.After visiting latrine/Toilet.
3.Before preparing food
4.Before feeding baby
5.Before eating meal.
6.Every time when I touch something dirty
7Others (Specify)________________________
52.Can you please show me how you wash your hands?
1.Yes
2.No
3.No water available for hand washing
53. (a) Does the respondent pose the right skills for washing hands? (Observe)
(Tick the steps below. if the respondent follows all steps then mark yes if not then mark
No)
1.Yes
2.No.
1. Wets hands
2. Lathers with soap
3. Rubs hands, wrists, palms and in between fingers
4. Rubs for at least 10 seconds
5. Cleans dirt under finger nails
6. Air dries hands or uses a clean cloth
7. Use of sufficient water (1 cup or more)
54.a) Is there a hand washing facility?
1.Yes
2. No
b) If yes, which type?
i)
Tilting can
ii)
Leak tins
iii)
Stand pipe
iv)
Basin
v)
Sufuria
55.Is there soap at this location?
1.Yes
114
2.No
56.Do you have soap in the house?
1.Yes
2.No
57.Can I see your drinking water storage container?
(Confirm presence and circle one. If unable to see container confirm type orally)
1.Ordinary clay pot
2.Plastic jerry can
3.Plastic or metal bucket
4.Container with narrow mouth and tap
5.Superdrum/tank
6.Other, specify _________________________________
58.Does this container have a lid or cap? (Confirm by observation)
1.Yes
2.No
59.Can you please retrieve a small bit of water for me? (Observe).
1.Dip into container
2.Pour directly from container
3.Tap
60.Test free chlorine if they said they have treated current drinking water
1.Presence of Chlorine
2.Absence of Chlorine
3.Insufficient water for testing
61. a) Do you know some diseases associated with drinking contaminated water?
1. Yes
2. No
b) If yes, name them;
1.Typhoid
5.Malaria
2.Cholera
6.URTI
3.Intestinal warms
7.HIV/AIDs
4.Diarrhoea
8.Others (specify)_________________________
c) How can we prevent these diseases mentioned above?
1.Boiling water
2.Use of household filters
3.Use of water guard
4.Treating water with PUR
115
5.Go to Hospital
6.Traditional healer
7.Others(specify)___________________
62.Who collects water for the family?
1. Men
2. Women
3. Children
63 a) How is water stored in the household container/Covered (Observe) 1.Open container 2.
b) How do you draw water from the container?
1 Dipping
2 Pouring
3.Tapping
c) Do you keep the container for drawing water?
1.On the floor.
2.Container with handle
3.In the cupboard
4.No special place
G:Diseases:
63. What diseases have the under five suffered for the last six months (1Record 2. History)
1. Malaria
2. Intestinal worms
3. T.B
4. Scabies
5. Eye diseases.
6. Diarrhoea
7. Respiratory
infections
8. HIV/AIDs
9.Measles
10.Others
64. What disease is/are the under five suffering from at the time of the visit? (By signs,
symptoms and observation)
1. Fever
2. Coughing
3. Measles
4. Scabies
5. Eye diseases.
6. Diarrhoea
7. Respiratory infections
8. No disease.
9. Others specify______________________________
65. Do you know the cause of the disease you have mentioned?
1. Yes
2. No
116
66. If sick where do you go for treatment?
1.Hospital/Health Facility
2..Buy medicines in the shops
3.Traditional healers.
4.Prayer.
5.Traditional beliefs
..... END.....
THANK THE RESPONDENT
117
APPENDIX 2: WATER SAMPLING AND REPORT FORM
For laboratory testing, please take a sample of water from the container where households store
drinking water.
Household
number
Sample number Mg/L chlorine
level
Faecal coliform Total coliform
Count (%)
Count (%)
118
Water culture
results
APPENDIX 3: Biochemical reaction of Enterobacteriaceae, Aeromonas and
pleisomonas after 18-24 hours incubation at 350C.
TSI agar
LIM medium
OrgaSlun Gas H2S Lys Mot Ind MR VP S.C Ure Ox
nism t/Bu
s
tt
*Escd
+/ -
d
d
+
+
-
-
-
-
+
+
-
+
-
+
-
+
d
-
/+
-
-
+
+
+
-
+
+
-
/+
-
-
+
+
+
-
+
+
-
/+
+
+
+
+
+
-
-
-
-
heri / +
chia
Cit. d
freu / +
ndii
C.
+
dive +
rsus
C.
+
amal+
oneti
cus
Edw adsi +
119
ella
tard
a
E.
+
/+
+
+
+
+
+
-
-
-
-
/+
-
+
-
-
d
+
+
-
-
d
-
d
-
-
+
-
d
d
-
-
-
-
-
-
+
-
-
-
-
/+
-
+
-
+
-
+
+
+
-
hosh +
inae
Kleb +
siell +
a
pneu
moni
ae
K.
d
ozae / +
nae
K.
d
rhin / +
oscl
ero
mati
s
K.
+
120
oxyt +
oca
Hafnd
ia
+
-
+
+
-
d
d
d
-
-
/+
-
-
+
-
-
+
+
-
-
/+
-
-
+
d
d
+
+
-
-
/+
-
+
+
-
-
+
+
-
-
/+
-
+
+
-
d
+
+
+
-
/ +
alvei
Ente +
roba +
cter
cloa
cae
E.
+
saka +
zakii
E.
+
aero +
gene
s
E.
+
gerg +
ovia
e
121
E.
d
d
-
-
d
d
d
d
d
d
-
/d
-
+
+
-
-
+
+
d
-
/-
-
d
+
-
d
+
+
-
-
/d
-
d
+
-
d
d
+
-
-
/d
-
-
+
-
d
+
+
-
-
d
+
-
+
+
+
-
d
+
-
aggl / +
ome
rans
Serr +
atia +
mar
cesc
ens
S.
+
mani+
roru
bra
S.
+
lique+
facie
ns
S.
+
plym +
uthic
a
Prot d
122
eus / +
vulg
aris
P.
d
+
+
-
+
-
+
d
+
+
-
/d
-
-
+
+
+
-
-
+
-
+
-
-
+
+
+
-
+
-
-
-
-
-
+
+
+
-
+
-
-
d
-
-
+
+
+
-
+
+
-
mira / +
bilis
Mor gane +
lla
mor
gani
i
Prov d
iden / +
cia
alkal
ifaci
ens
P.
d
stua / +
rtii
P.
d
123
rettg / +
eri
*
+
/-
-
-
-
d
+
-
-
+
-
/-
-
-
-
-
+
-
-
+
-
/d
-
-
-
+
d
d
-
+
-
/d
-
-
-
+
d
d
-
+
-
Yers +
inia
ente
roco
litic
a
Y.
-
pseu +
dotu
berc
ulosi
s
Y.
+
inter +
medi
a
Y.
+
fred +
eriks
enii
124
Y.
-
/
-
-
-
d
+
-
/-
-
-
-
d
+
-
-
-
-
/d
-
-
-
-
+
-
-
-
-
/d
-
-
-
+
+
-
-
-
-
+/
+/
-
+
-
+/
-
-
krist +
ense
nii
*
-
Shig +
ella
in
gene
ral
* S. flex +
neri
6
* S. boyd +
ii 13
&
14
Sal - // / + / +/
mon +
ella
125
*S. -
/+
+
+
+
-
+
-
+
-
-
/-
+// +
+/
-
+
-
-
-
-
/+
-//
-
+
-
+
-
-
-
-
/+
-//
d
+
-
+
-
-
-
-
/+
d
+
+
-
+
-
d
-
-
chol +
erae
suis
in
gene
ral
* S. typh +
i
* S. para +
typh
iA
* S. send +
ai
* S. chol +
erae
suis
126
* S. -
/+
-
-
+
-
+
-
-
-
-
/+
-
+
+
-
+
-
-
-
-
/+
-
+
+
-
+
-
-
-
-
/d
d
+
-
-
+
-
-
-
-
/+
-
d
+
+
+
+
d
-
+
typh +
isuis
* S. abor +
tuse
qui
* S. abor +
tuso
vis
* S. galli +
nar
um
*
+
Aero+
mon
as
hydr
ophi
la
127
* A. +
/+
-
d
+
+
+
+
d
-
+
/-
-
-
+
+
+
-
d
-
+
/-
-
+
+
+
+
-
-
-
+
/-
-
+
+
+
+
-
-
-
+


*: Enteropathogenic
In TSI medium - -/+, ferment glucose only; +/+ ferment glucose, and lactose or sucrose
or both; d/+ ferment glucose and fermentation of lactose or glucose shows different
reactions; Gas, gas from glucose(TSI).
sobr +
ia
A.
+
cavi +
ae
*Ple isom +
onas
shig
elloi
des
(Vib rio +
para
hae
moly
ticus
)
Keys:
128

Lys. – lysine decarboxylase; Mot.- motility; Ind. – indole(LIM); MR, - methyl red;
VP, - Voges-proskauer; S.C, - citrate; Ure, - urease; Ox, - cytochrome oxidase; -,
negative; +, positive; d, different reactions; +/, rarely negative; -//, rarely positive.
APPENDIX 3: MAP OF STUDY AREA
APPENDIX 4: ETHICS AND RESEARCH CLEARANCE
APPENDIX 5: PUBLISHED PAPERS
129
130
131